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Building institutions through equitable partnerships in global health

Conference report

May 2012

Academy of Medical SciencesThe Academy of Medical Sciences promotes advances in medical science and campaigns to ensure these are converted into healthcare benefits for society. Our Fellows are the UK’s leading medical scientists from hospitals and general practice, academia, industry and the public service. The Academy seeks to play a pivotal role in determining the future of medical science in the UK, and the benefits that society will enjoy in years to come. We champion the UK’s strengths in medical science, promote careers and capacity building, encourage the implementation of new ideas and solutions – often through novel partnerships – and help to remove barriers to progress. www.acmedsci.ac.uk

The Royal College of PhysiciansThe Royal College of Physicians has been supporting and representing physicians for nearly 500 years. Our roots stretch back to Henry VIII, but our members today work in the fast-paced, ever-changing, highly technological world of medicine. • We support our physician fellows and members during every stage of their careers, and in doing

so improve the quality of patient care. • We set and monitor standards of medical training to ensure that patients are treated by fully

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and scrutinising clinical care.• Our education programmes provide physicians with the knowledge and skills they need for high

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In addition to supporting physicians in their daily practice, we take a wide role in public health. Our activities include campaigning for change, advising government and Parliament, and taking part in national debates on medical, clinical and public health issues. www.rcplondon.ac.uk

Wellcome TrustWe are a global charitable foundation dedicated to achieving extraordinary improvements in human and animal health. We support the brightest minds in biomedical research and the medical humanities. Our breadth of support includes public engagement, education and the application of research to improve health. We are independent of both political and commercial interests. www.wellcome.ac.uk

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Universities UKUniversities UK is the representative organisation for the UK’s universities. Founded in 1918, our mission is to be the definitive voice for all universities in the UK, providing high-quality leadership and support to our members to promote a successful and diverse higher education sector. With 134 members and offices in London, Cardiff and Edinburgh, we promote the strength and success of UK universities nationally and internationally. www.universitiesuk.ac.uk

ISBN No: 978-1-903401-34-7

Building institutions through equitable partnerships in global health

Conference report

May 2012

2

Acknowledgements

This report is published by the Academy of Medical Sciences, the Royal College of Physicians, the

Wellcome Trust, the Bill and Melinda Gates Foundation and Universities UK. The partners warmly thank

Professor Philippa Easterbrook, Professor Robert Souhami CBE FMedSci, the steering committee, the

session Chairs, the speakers and the delegates for their participation and contributions.

The partners gratefully acknowledge the support of Pfizer for this event.

© The Academy of Medical Sciences

BUILDING INSTITUTIONS THROUGH EQUITABLE PARTNERSHIPS IN GLOBAL HEALTH

3

CONTENTS

Contents

Summary 5

1 Introduction 9

2 The changing landscape of partnerships 13

3 Benefits of and challenges to institutional partnerships 21

4 Education, training and career development 25

5 Building institutional capacity 31

6 Funding and sustainability 35

7 Evaluation of partnerships 39

8 Engaging new disciplines, new topics and new places 45

9 Conclusion 51

Annex I: Organising and steering committees 53

Annex II: Acronyms and abbreviations 55

4


5

Universities across the world combine

strengths in research, education, training and

health service delivery, along with access to

multiple disciplines within a single institution.

International partnerships between universities

and other academic institutions in the North and

South offer an important way to tackle the global

health challenges of the 21st century, including

the Millennium Development Goals. They also

play an important role in building capacity in

research, education, training and health services

in developing countries.

Over the past decade there has been a welcome

expansion of the number and type of global

health partnerships. However, discussion of the

optimal role of universities has been limited.

Of particular importance is the identification

of types of partnership that meet the needs

of Southern institutions and build capacity

for the future. These considerations led five

organisations with active involvement in capacity

building and partnerships – the Royal College of

Physicians, the Academy of Medical Sciences, the

Wellcome Trust, Universities UK and the Bill and

Melinda Gates Foundation – to host a conference

on this topic. The event brought together

leaders from 21 different countries to share best

practice and lessons learned. A priority was to

ensure Southern voices were heard, with many

participants from Africa, South Asia and South

America. Although many types of partnership

were considered, the conference focused on

those between academic institutions.

This report summarises the issues that were

discussed at the conference and presents five

priorities for action.

Types of partnership

In addition to the traditional North–South

partnership, newer models have emerged

that include South–South partnerships and

networks, multi-institutional research networks

and consortia, public–private partnerships,

professional society partnerships and technical

assistance partnerships. Discussion revealed the

following issues:

• The experience with some of these different

partnership models is still recent and their

relative contributions, as well as benefits and

weaknesses, may not be clear for some time.

• There was strong support for the expansion

of South–South partnerships with Northern

links, as well as partnerships that integrate

research, health service delivery, training

and capacity development as these

represent the most sustainable and equitable

type of institutional partnership.

• There is a need for clearer terminology

relating to partnerships.

• There is also a need for a forum to facilitate

better links between existing networks

and to allow institutions and partnerships

to share information and experiences.

Networking organisations such as the

European Academic Global Health Alliance

(EAGHA) and the Consortium of Universities

for Global Health (CUGH) could play this role.

Benefits of and challenges to partnerships

Partnerships offer considerable mutual benefits

both to the Northern and Southern institutions.

The most important of these are as follows:

access to shared scientific resources, expertise

and ideas; mutual learning and knowledge

exchange; greater access to financial resources;

improved research quality; productivity and

impact; and opportunities for individual and

institutional capacity building.

The resulting challenges include increased

workload, complex management and logistical

implications, and imbalance within partnerships

owing to inevitable differences in available

resources and infrastructure between Northern

and Southern institutions. Inequitable

Summary

SUMMARY

6

partnerships remain common and there is a need

for this to change.

Principles of partnership

A clear conclusion from the conference was that

excellent people are the foundation of successful

partnerships. Partnerships are about relations

between people and research for a purpose. This

means that the function of a partnership must

be determined at the start. Clear objectives need

to be stated, as do the terms of engagement,

deliverables, timescales, allocation of funds

and resources. This enables a framework for

progression, monitoring and evaluation.

Partnerships must be dynamic, relevant and

equitable, engaging all parties in a way that is

mutually beneficial. This requires an investment

from every member of the partnership:

researcher, administrator, health practitioner,

funder, policymaker or local community member.

Opportunities for training and career progression

are essential, as is mentorship, financial reward

and practical support.

All partners need to recognise and value each

other’s respective strengths and embrace the

opportunity to learn from them. No one partner

should dominate and all partners should be able

to contribute on the same terms. The research

undertaken by the partnership needs to be

relevant to the community in which the research

is undertaken, focusing on local health priorities

rather than perceived needs observed by

partners. Governance issues, such as intellectual

property, ownership and authorship, require

agreement at the start of a partnership, and

the evaluative framework should be based on

published, recognised models of best practice.

Interdisciplinary skills and translational research

should also be encouraged.

Priorities for action

The five priority areas for action identified at the

conference were as follows:

Priority 1: Nurture postdoctoral fellows and

postgraduate students

Postgraduate and postdoctoral training in

Southern institutions continues to be challenged

by lack of capacity in skilled mentorship, limited

research orientated career pathways and poor

institutional infrastructure and support. There is

a major gap in postdoctoral career structures in

Southern institutions that contributes to a brain

drain to the North that undermines capacity

building and ultimately weakens partnerships.

Too often postdoctoral scientists move into

responsible administrative and management

positions when they need more time to

consolidate their research programme. A major

priority identified at the conference was the need

for additional support from Southern institutions

and funders for postdoctoral researchers from

the South. Proposals included the following:

• PhD ‘finishing schools’ to further develop

skills in grant and manuscript writing, IT,

management and leadership, and building

networks.

• Expansion of career development and

re-entry fellowship incentive schemes to

encourage PhD graduates to undertake

postdoctoral work in their home country.

• The need for Southern institutions to provide

a supportive environment and introduce

more flexibility into their career structure

through protected research time and

administrative support.

• Measures to ‘train the trainers’ through

courses in mentorship and shared

supervision, mentorship between faculty

across Southern and Northern institutions,

and student and faculty exchanges using

regional South–South and South–North

networks.

Other opportunities to improve education,

training and career development in the South

include the following:


7

• Expansion of the successful model of

sandwich and joint PhDs, and short overseas

placements.

• Greater development of electronic and

distance learning, particularly through

affordable access to the distance learning

materials of Northern institutions.

• Additional piloting and evaluation of

sustainable financing mechanisms for

training, such as the social business model.

• Engaging diasporas to support training in

their home country.

• Support for early development of interest in

science in secondary schools.

Priority 2: Strengthen institutions

Funders and Southern governments should direct

more resource to the building of institutional

capacity, while Northern institutions can

provide support through sharing of systems and

expertise. Priority areas for development in the

South include the following:

• Establishing central research support centres

for research management within institutions.

• Progressive integration of grants and

financial management of existing North–

South partnerships into central university

infrastructures.

• Ensuring a more equitable and transparent

arrangement for distribution of overheads to

support infrastructure between Southern and

Northern institutional partners.

• Providing faculty management training

earlier in the career path in areas such as

financial and personnel management, and

leadership development.

• Creating advocates for global health

partnerships and capacity building at senior

positions within institutions.

• Developing institutional and national

policies on the legal and ethical framework

for partnerships, intellectual property and

transfer of samples.

• Ensuring Northern universities recognise

and support activities of their staff engaged

in international capacity building work in

Southern institutions.

Priority 3: Engage decision makers and

funders from the South

The most successful partnerships are long-

term endeavours and require sustained core

funding. With the global economic downturn

and slowdown in global health funding,

sustainable funding for partnerships and

capacity building needs to diversify beyond the

traditional dependence on external agencies.

Southern governments, Southern funders and

Southern philanthropists need to be more

fully engaged with global health partnerships

and capacity building. This might be achieved

by demonstrating the benefits of these

arrangements. Researchers, universities and

funders should encourage those from the South

to invest in sustainable global health research

partnerships that build research capacity. Key

proposals discussed at the meeting included the

following:

• The more equitable sharing of overheads

between Northern and Southern partners.

• The use of Southern government tax

revenue for health research and capacity

building.

• Engagement with local business corporate

social responsibility funds, philanthropic

funds, and public–private partnerships.

• Strategies for more sustainable funding

include longer-term project funding schemes

as partnerships take time to produce

results, a social business model for training

initiatives and development of institutional

endowment funds.

Priority 4: Develop new evaluation capacity

and evaluation techniques

Evidence of the value of global health

partnerships and capacity building is limited.

Evaluation of partnerships is critical to

demonstrate benefits and impact, to assess

whether goals have been met, and to

develop best practice. However, evaluation

of partnerships and capacity building is a

new science that currently lacks a strong

evidence-base and has few validated measures.

Researchers, universities and funders interested

in global health research should use existing

SUMMARY

8

resources to develop new methods of evaluation.

Additional priorities are as follows:

• To increase capacity by training a cadre

of individuals competent in evaluation

methodology, especially in the South.

• To unify reporting requirements for different

funders to minimise onus on institutions

with multiple partnerships. This might be

achieved by improving the co-ordination

of evaluation tools and indicators through

the ESSENCE network, together with

consideration of the establishment of a

register of the results of the evaluation of

major grants.

• To increase submission of high-quality

evaluation experiences to peer-reviewed

journals.

The following principles were proposed for

evaluating partnerships:

• The establishment of plans and funds for

rigorous, prospective evaluation at the

inception of partnerships.

• Regular evaluation throughout the life of a

partnership – at planning, implementation,

dissemination and wrap-up.

• Joint development of evaluation tools and

indicators (quantitative and qualitative)

by partners and regular revision to

accommodate changes to the nature of the

partnership.

• The inclusion of measures of benefits to local

communities.

• The need to build on existing evaluation tools

with project specific adaptations.

• Longer-term evaluation as some outcomes

of capacity building activity may take many

years to show an impact.

Priority 5: Involve new disciplines and

places

Growth in partnerships and capacity has been

uneven geographically and in the focus of their

research and the disciplines involved. The need

for interdisciplinary working is driven primarily

by the need for a more co-operative approach

to addressing complex global health challenges.

Universities and associated partnerships offer a

unique opportunity for interdisciplinary working

through their access to multiple disciplines.

Specific strategies to promote interdisciplinary

working include the following:

• Expanding interdisciplinary training

programmes and research opportunities

such as exchange of modules from different

courses or distance learning programmes.

• Incorporating interdisciplinary training

opportunities at an early stage in career

structures.

• Promoting interdisciplinary research funding

schemes.

• Increasing representation of social sciences,

such as psychology, nutrition and health

economics, in existing partnerships.

• Encouraging recognition and reward

for interdisciplinary working within the

university sector.

• Greater efforts are needed to establish

equitable, sustainable partnerships and

capacity in both underserved regions such

as central Africa, French and Portuguese

speaking countries, and fragile states, and

in neglected disciplines and topics such as

health systems research, nutrition,

the social determinants of health and

non-communicable diseases.

Progress on global health will depend on

commitment to developing partnerships with

these priorities in mind. This will involve

Northern and Southern institutions, including

universities, academies of medical sciences,

organisations responsible for professional

training and government agencies, as well as

research funders.


9

1 Introduction

1.1 Background

The global health challenges of the 21st

century can no longer be defined by nations or

geographical regions alone, so they require new

collaborations and new ways of collaborating.

International partnerships between academic

institutions and other organisations in the North

and South offer one such approach. They can

also play an important role in building research,

education, training and health service capacity in

developing countries.

Several organisations, as well as individuals,

have proposed some principles to help guide

the establishment and development of equitable

global health partnerships. These organisations

and individuals include the following:

• The Commission for Research Partnerships

with Developing Countries (KPFE) ‘Swiss

principles’.1

• The Netherlands Development Assistance

Research Council (RAWOO) principles.2

• Professor Anthony Costello FMedSci and

Professor Ali Zumla FMedSci from University

College London, UK.3

• The Council on Health Research for

Development (COHRED).4

• The Canadian Coalition for Global Health

Research (CCGHR) partnership policy.5

• Oxfam GB Partnership Policy and five

principles of partnership.6

The key principles set out in these reports are

detailed in Annex V. However, there are several

important gaps, including the following:

• A focus on traditional North–South

partnerships.

• Limited input from and perspectives of

Southern partners.

• Few actionable steps to achieve the

recommended goals for improved

partnerships.

• Less focus on evaluation of outcomes,

successes and difficulties.

So far, there has also been limited discussion

about the optimal role of the university in global

health partnerships. Of particular importance are

the types of future partnership between Northern

and Southern institutions that will meet Southern

needs and priorities, as well as building and

sustaining capacity for the future.

These considerations led five organisations

with active interest in capacity building and

partnerships – the Royal College of Physicians,

the UK Academy of Medical Sciences, the

Wellcome Trust, Universities UK and the Bill and

Melinda Gates Foundation – to hold a conference

on this topic in April 2011. The meeting and

report were developed with the advice of a

steering committee, as detailed in Annex I.

1.2 Conference objectives

The conference brought together leaders and

researchers from 21 different countries to share

best practice and lessons learned in institutional

partnerships (see Annex III). Universities,

philanthropic organisations, non-governmental

organisations (NGOs) and the private sector

were represented. The conference included those

with established partnerships, as well as those

planning to develop such programmes. It was

underpinned by several guiding principles:

1 KPFE (1998). Guidelines for research in partnership with developing countries. http://www.int.uzh.ch/northsouth/KFPEGuidelines.pdf2 Netherlands Development Assistance Research Council (2001). North-South research partnerships: issues and challenges.

Trivandrum expert meeting report, 1999. The Hague, The Netherlands.3 Costello A & Zumla A (2000). Moving to research partnerships in developing countries. BMJ 321, 827–829.4 COHRED (2004). Principles of good partnership for strengthening public health capacity in Africa.

http://www.cohred.org/wp-content/uploads/2011/05/783.pdf5 Canadian Coalition for Global Health Research (2007). Building respectful and collaborative partnerships for global health research:

learning resource. http://www.ccghr.ca6 Oxfam (Unknown). Working with others. Oxfam GB partnership policy. Five principles of partnership.

http://www.oxfam.org.uk/resources/accounts/downloads/partnership_policy_principles.pdf

1 INTRODUCTION

10

• A focus on partnerships between

universities and academic institutions at the

postgraduate level and on partnerships that

involve research, training and health service

delivery.

• Inclusion of perspectives of Southern

partners and institutions: many of the

invited speakers and panellists were from

institutions in Africa, Asia and South

America, and the meeting sought to address

their priorities and concerns.

• The importance of building on previous

reports and recommendations on

partnerships and to identify new ideas and

approaches.

The conference was divided into 11 sessions

over 2 days (see Annex IV for the programme).

Specific aims of the meeting were as follows.

• To identify and discuss the factors that

contribute to both successful, equitable

partnerships.

• To identify and discuss the challenges

that hinder the development of successful

partnerships.

• To address strategies to improve individual

and institutional capacity building.

• To address the challenge of securing

sustainable, long-term funding for

partnerships.

• To address how best to incorporate

monitoring and evaluation of partnerships.

• To identify strategies to improve

interdisciplinary working.

• To highlight the specific needs of Southern

partners and how these can be addressed.

1.3 Nomenclature

The nomenclature used to describe different

aspects of global health partnerships is

constantly evolving. Some terminology

maybe contentious given the understandable

sensitivities associated with the inequalities that

currently exist between countries. Although this

conference report does not seek to provide

a definitive nomenclature for global health

partnerships, a brief note on three aspects of

terminology is given below:

1.3.1 North and South

The terms ‘North’ and ‘South’ are frequently

used in this report as shorthand for high-income

countries and low-income and middle-income

countries respectively, or for the ‘developed’

and ‘developing’ world. However, the terms

are not synonymous and their limitations are

acknowledged. Challenges in global health

cannot be defined by geography alone. The

growth rate of several low- and middle-income

countries outpaces many developed economies.

There is a focus on Africa in many of the

examples presented, reflecting the experiences

of participants or speakers, although there were

also important models reported from Asia and

Latin America.

1.3.2 Capacity building

During the course of the conference, there was

some discussion as to whether the term ‘capacity

building’ should be replaced by ‘capacity

strengthening’ or ‘capacity development’, which

better acknowledges existing capacity and

expertise. This report adopts the term ‘capacity

building’, as this is the one most commonly used

in the literature.

1.3.3 Partnership

The diversity of global health partnerships meant

that it would have been difficult to cover every

type of partnership in detail during a two-day

conference. Although many types of partnership

were touched upon at the conference, discussion

focused on research partnerships between

academic institutions at the postgraduate level

and beyond.

1.4 Overview of the reportChapters 2 and 3 of this report consider the

recent expansion of different types of global

health partnership and the benefits and

challenges associated with them. Chapters

4–8 consider particular challenges that these


11

partnerships face and strategies to address them

in terms of doctoral and postdoctoral training,

building institutional capacity, establishing

sustainable funding and approaches to

evaluation. Chapter 9 offers a brief conclusion.

Annexes I and II can be found at the end of the

report whereas the remainder can be accessed

online at www.acmedsci.ac.uk

This report highlights actionable steps identified

at the meeting that will allow partnerships to be

better established, maintained and evaluated.

These actions are given in the summary section

at the beginning of the report and in the

concluding sections of each chapter.

Throughout this report, unless otherwise stated,

suggestions and recommendations are those

put forward and supported by many of the

participants. They do not necessarily imply

agreement by the entire body of participants and

or the corporate positions of the partners that

organised the event.

1 INTRODUCTION

12


13

2 THE CHANGING LANDSCAPE OF PARTNERSHIPS

2 The changing landscape of partnerships

2.1 Introduction

Many early global health partnerships developed

from the practice of Northern institutions

obtaining samples and data from Southern sites.7

Where partnership existed it was often between

those in the North and Northern scientists and

administrators based in Southern institutions.

Later partnerships involved Northern researchers

spending a few weeks in a developing country

to collect samples, or were designated sites

with expatriates based in Southern countries.

Although many of these partnerships involved

capacity building they were sometimes

inequitable, an issue which is discussed further in

Chapter 3.

Several factors, listed in Box 2.1, present new

opportunities and challenges for global health

partnerships.

Box 2.1 New opportunities and challenges for global health partnerships

1. The rapidly increasing, but now levelling investment, in global health, with increased

opportunities for private sector funding (see Chapter 6).

2. Funding schemes specifically aimed at partnerships from organisations such as the Wellcome

Trust, European and Developing Countries Clinical Trials Partnership (EDCCTP), National

Institutes of Health (NIH) Medical Education Partnerships Initiative (MEPI) programme and the

Doris Duke Foundation (see section 2.3.1).

3. Progressive increase in scientific and economic power of emerging economies such as China,

India and Brazil.8

4. Intense interest and engagement in global health by academic institutions and students,

especially in North America.9

5. Emergence of inexpensive rapid communications and mobile phone technologies, making it

possible for researchers to work together effectively without the need for long-distance travel.

6. Proliferation of stakeholders and organisations involved in global health, including multilateral

agencies and think-tanks.

7. A push toward greater country ownership of programmes and for more integration of vertical

programmes, which currently focus on particular disease areas.

8. Demographic transition in low- and middle-income countries, and the rising burden of non-

communicable diseases.10

9. Re-engagement of universities in research, especially in sub-Saharan Africa, reversing a

twenty year trend for research leadership by independent institutions.

7 Rathgeber E (2009). Research partnerships in international health: capitalising on opportunity. http://berlin.tropika.net/public-access/stakeholders-meeting/background-papers/background-paper.pdf

8 UNESCO (2010). UNESCO science report 2010. http://www.unesco.org/new/en/natural-sciences/science-technology/prospective-studies/unesco-science-report/

9 Further details are available from http://www.cugh.org/10 Further details of the work of the United Nations on non-communicable diseases is available from

http://www.un.org/en/ga/president/65/issues/ncdiseases.shtml

14

2.2 New types of partnership

Over the past 10 years there has been a

marked proliferation of many different types of

partnership in health and research. Partnerships

can be classified by both the focus of their work

(clinical care, research, training and capacity

building) and the type of partners involved.

The latter includes those between individuals,

those between institutions and those involving

consortia or networks of institutions (see

section 2.3.2). The overall benefits and costs of

partnerships are considered in detail in Chapter

3 but, in addition, each of these different models

has its own strengths and weaknesses that are

summarised in Table 2.1.


2.3 New models of partnership

Within university and research institutions,

there has been a marked growth in new types of

partnership. These include the following:

• South–South partnerships and networks.

• Multi-institutional research networks and

consortia.

• International university branch campuses.

• Public–private partnerships.

• Professional society partnerships.

• Technical assistance partnerships.

These models are described below and many

overlap: for example, research consortia may

include South–South partnerships and vice versa.

Type of

partnership

Advantages Disadvantages

Individual to

Individual

• Personalchoiceandcommitment.

• Mutualbenefitforbothresearchers.

• Flexible.

• Costeffective.

• Nodirectinstitutionalstrengthening.

• Benefitsonlyindividualresearchers.

Institution to

institution

• Sharingresourcescanbeofbenefit

to both institutions.

• Canprovidecontinuitythatisnot

dependent on individuals.

• Establishesaframeworkfor

research capacity development.

• Canestablishclearagreements

on sensitive issues such as data

sharing, IP and publication.

• Facilitatedbynewcommunications

technologies.

• Thepartnershipcanbedominated

by one institution.

• Individualresearchersmaybe

pushed into ‘forced marriages’.

• Aformal,time-definedagreement

can tie one or other partner

into a long-term, unproductive

relationship.

• Terminationofthepartnership

canbedifficultandhavewider

consequences such as an impact

on broader relations between

institutions.

Consortium or

network

• Preventsduplicationofresearch.

• Allowsharingofideaswithoutfear

of competition.

• Providesincreasingopportunities

for Southern leadership.

• Toomuchinvestmentcangointo

maintaining the infrastructure of

the consortium.

• Canstiflescientificcompetitionand

inventiveness.

• Cancausetensionsbetween

partners who do not agree with the

‘consortium’s view’.

Table 2.1 Advantages and disadvantages of different types of partnership

15

2.3.1 South–South partnerships

South–South partnerships break the model of

passive, unidirectional transfer of knowledge and

technology from North to South by mobilising the

existing capacities and resources of the Southern

countries involved. Resources can be pooled to

work on shared problems and common priorities,

as well as expanding training opportunities

regionally to build indigenous research capacity.

Shared experience, geography and language

frequently contribute to a greater degree of trust,

facilitating the development and maintenance

of non-competitive partnerships that focus on

horizontal cross cutting health issues. Examples

are given in Box 2.2.


Box 2.2 Examples of South–South partnerships

The African-led Initiative to Strengthen Health Research Capacity in Africa (ISHReCA) is a

partnership of health researchers from over 30 African healthcare institutions. It provides a forum

for African scientists to share ideas on capacity building and communicate directly with funders.

Further details are available from http://ishreca.tropika.net/.

The International Network for the Demographic Evaluation of Populations and Their

Health in Developing Countries (INDEPTH) is a global network of members who conduct

longitudinal health and demographic evaluation of populations in low- and middle-income

countries. INDEPTH aims to strengthen global capacity for Health and Demographic Surveillance

Systems (HDSS), and to mount multi-site research to guide health priorities and policies in

low- and middle-income countries, based on up-to-date scientific evidence. Further details are

available from http://www.indepth-network.org/.

A partnership linking the Union de Naciones Suramericanas (UNASUR) and the Community

of Lusophonic Countries (CPLP) has led to the development of joint UNASUR/CPLP health

councils and capacity building initiatives including the following:

• Fiocruz Master programmes in Public Health and Biomedical Sciences at institutes in

Mozambique, Angola and Argentina.

• PhD and Masters programmes for CPLP and UNASUR students at Fiocruz, incorporating

‘sandwich’ placements in partnership countries.

• An innovative training project whereby Technical School teachers teach the teachers of

partner countries.

Participants welcomed the recent establishment

of funding schemes to support South–South

partnerships from organisations such as the

Wellcome Trust, US National Institutes of

Health (NIH), Doris Duke Foundation and the

European and Developing Countries Clinical Trials

Partnership (EDTCP). Many of these South–South

schemes continue to involve Northern partners

to support specific activities. Examples include

the Wellcome Trust African Institutions Initiative

(detailed in Box 2.3) and the various training

initiatives of the Public Health Foundation

of India (PHFI).11 Many participants agreed

that institutional partnerships that integrate

research, service delivery, education and

capacity development are the most valued type

of partnership.

11 Further details of the Public Health Foundation of India can be found at http//www.phfi.org/

16

2.3.2 Research networks and consortia

Although university partnerships continue to

form the basis of many collaborative initiatives,

research focused multi-institutional networks

and consortia are becoming more prevalent,

with specific funding schemes for networks

of excellence and large consortia through the

European Union, NIH and Gates Grand Challenge

Programmes.12 By their very nature, research

consortia may also involve partnership between

a wide range of stakeholders, including hospitals,

government agencies, charitable foundations and

the private sector. These complex partnerships

are able to realise research goals beyond the

scope of smaller collaborations, such as the

completion of expensive, large-scale late-phase

clinical trials. Examples include the following:

• The Stillbirth Alliance13

• The Malaria Capacity Development

Consortium (MCDC)14

• The ALPHA HIV Cohort Network15

• The TB Vaccine Consortium16

Frequently directed at HIV, tuberculosis and

malaria, research consortia offer a co-ordinated

approach to the design and execution of a

focused programme of research. Consortia

offer shared facilities, ideas, mentorship,

training schemes and data management that

build on the research strengths of individual

groups, as well as providing funding for regular

teleconference and workshops. Key advantages

are that they provide a stimulating environment

and critical mass for development and sharing

of research ideas without fear of competition,

prevent research duplication, even out the power

imbalances between institutions, and provide

increasing opportunities for Southern leadership.

Challenges include stagnation due to lack of

competition, the time-consuming distraction of

multiple network-related teleconferences and

meetings, and the reluctance of some partners to

be co-ordinated.17


Box 2.3 Wellcome Trust African Institutions Initiative

The £30 million African Institutions Initiative aims to develop institutional capacity to support and

conduct health-related research vital to enhancing health, lives and livelihoods in sub-Saharan

Africa. It aims to strengthen Africa’s universities and research institutions, and to help in the

development of networks for health-related research.

More than 50 institutions from 18 African countries are partnered in seven international and

pan-African consortia. Each is led by an African institution and includes research and higher

education partners as well as research institutes from Europe, the USA and Australia.

Each of the consortia operates independently and sets its own agenda. Activities include leadership

training and professional development, PhD and postdoctoral fellowships, improved infrastructure,

competitive grant schemes and the provision of up-to-date equipment. Further information is

available from http://www.wellcome.ac.uk/Funding/International/WTX055734.htm.

12 Further details of the Grand Challenges can be found at http//www.grandchallenges.org/Pages/Default.aspx13 Further details on the International Stillbirth Alliance are available from http//www.stillbirthalliance.org/14 Further details of the MCDC are available from http//www.mcdconsortium.org/index.php15 Further details of the ALPHA HIV cohort network are available from http//www.lshtm.ac.uk/eph/psd/alpha/16 Further details of the TB Vaccine Consortium are available from http://www.tbvi.eu/17 Dockrell H (2010). The role of research networks in tackling major challenges in international health. International Health 2(3), 181–185.

17


18 The Observatory on Borderless Higher Education (2009). International branch campuses: markets and strategies. http://www.obhe.ac.uk/documents/view_details?id=770

19 Further details of GAVI are available from http//www.gavialliance.org/ 20 Further details of the Global Fund are available from http//www.theglobalfund.org/en/ 21 Further details of DNDi are available from http//www.dndi.org/ 22 Further details of PATH are available from http//www.path.org/index.php23 Further details are available from http//www.pfizer.com/responsibility/global_health/infectious_diseases_institute.jsp 24 Further details are available from http//directrelief.org/DiflucanPartnership/EN/DiflucanProgramOverview.aspx 25 Further details are available from http://www.ampathkenya.org/our-programs/primary-care-chronic-diseases/oncology/

2.3.3 International university branch

campuses

Over recent years there has been a rapid

expansion in the number of university branch

campuses based overseas, with 162 operating

globally in 51 different countries according to a

2009 survey.18 This represents a 43% increase

from 2006. Half of these are branches linked with

US institutions, 11% with Australian institutions

and 10% with UK institutions. There are also

11 Indian institutions with external campuses,

mainly in the United Arab Emirates. There is

often confusion between university branch

campuses and other types of global health

partnership.

2.3.4 Public Private Partnerships

Public Private Partnerships (PPPs) involve

private companies as well as other partners

such as governments, foundations and funders.

Examples of large PPPs include the Global

Alliance for Vaccination and Immunisation

(GAVI), which focuses on enhancing access to

vaccines in 72 countries, and the Global Fund to

Fight AIDS, Tuberculosis and Malaria, a major

financier of health programmes for these three

diseases around the world, with US$22.6 billion

committed to programmes in 150 countries.19,20

Other PPPs include the Drugs for Neglected

Diseases initiative (DNDi) and the Programme for

Appropriate Technology in Health (PATH).21,22

The pharmaceutical industry contributes in other

ways. For example, Pfizer is involved in several

partnerships including the following:

• Building and sustaining regional clinical

laboratory and medical training for diagnosis,

treatment and prevention of HIV/AIDS

at the Infectious Disease Institute in

Kampala, Uganda.23

• The Diflucan partnership provides

fluconazole free of charge to government

and non-government agencies in Africa to

treat opportunistic infection associated with

HIV/AIDS.24

• AMPATH Pfizer Oncology Group Partnership

is developing human capacity in Western

Kenya for treatment of cancer patients, and

has funded the establishment of a radiation

oncology facility, and provided equipment

and staff training.25

Lessons learned from these initiatives are the

importance of communicating the impact of

these programmes externally, and reliance on

strong local leadership and experience. There is

also a need to plan for a long-term commitment,

to provide resources beyond finance, and to

integrate the partnership into the company’s

business plans while ensuring that key internal

support is maintained.

2.3.5 Professional societies

Many professional societies in Europe and North

America are also building partnerships. One

example of such a partnership is the collaborative

programme between the West African College of

Physicians (WACP) and the UK’s Royal College of

Physicians (Box 2.4).

2.3.6 Technical assistance partnerships

with governmental and non-governmental

organisations

A key example of this type of partnership is the

US Centers for Disease Control (CDC) provision

of technical assistance to Ministries of Health,

multilateral organisations (e.g. the World Health

Organization (WHO), Global Fund, UNICEF,

UNAIDS and World Bank) and global NGOs

(e.g. CARE, Red Cross, Rotary International

18

Box 2.4 West African College of Physicians (WACP) and UK Royal College of Physicians Partnership

In 2008, the WACP and Royal College of Physicians (London) signed a formal agreement to

improve standards of training in West Africa, with the broader aim of advancing medicine and

improving patient care.

The partnership focuses on strengthening the capacity of the WACP to train physicians in two main

areas: medical education and clinical sub-specialty skills. The three-year project was launched in

2009 and works in those countries with WACP membership: Nigeria, Ghana, The Gambia, Sierra

Leone, Liberia, Cote d’Ivoire, Benin and Senegal. The main activities supported through the

WACP include faculty development, clinical training, distribution of learning resources and a joint

scientific meeting.

The following lessons have emerged from this partnership:

• Partnerships work well when organisations have similar roles and culture. In this case the two

colleges are involved in examinations, postgraduate training and postgraduate curriculum

development, have a strong membership and a strong ethos of volunteering.

• Partnerships around a specific project provide the opportunity to forge broader organisational

alliances, and to attract additional outside funding.

• A major challenge has been the lack of a strong administrative infrastructure and capacity at

the WACP.

Further details are available from http://www.rcplondon.ac.uk/international/africa/rcp-and-wacp.


and GAVI Alliance). A wide range of technical

assistance is provided that includes building

laboratory expertise and capacity, conducting

epidemiological investigations, programme

monitoring and evaluation, building surveillance

systems, training in-country personnel and

development of public health leaders and

managers, and conducting applied research to

support activities and programmes.

The University of Washington International

Training and Education Center for

Health (I-TECH) is another example of a

multidisciplinary technical assistance partnership,

and is described further in Box 8.1.

2.3.7 Other types of partnership

Other types of partnership mentioned at the

conference include the following:

• Clinical partnerships between hospitals

supported by the UK-based Tropical Health

Education Trust (THET).26

• Organisational networks with a focus

on global health, such as the European

Academic Alliance for Global Health and

the CUGH.27,28 These networks offer

considerable opportunities but there

is a need to avoid excessive top-down

co-ordination that could stifle creativity.

26 Further details are available from http://www.thet.org/ 27 Further details on the EAGHA are available from http://www.eagha.org/ 28 Further details on the CUGH are available from http://www.cugh.org/

19


2.4 Conclusion

Over the past 20 years there has been

a considerable and welcome expansion

in the number, nature and size of global

health partnerships. In addition to the

traditional North–South partnership,

newer models have emerged that include

South–South partnerships and networks,

multi-institutional research networks and

consortia, public–private partnerships,

professional society partnerships and

technical assistance partnerships.

Discussions concluded the following:

• The experience with some of these

different partnerships models is still

recent, and their relative contributions

as well as benefits and weaknesses may

not be clear for some time.

• There was strong support for the

expansion of South–South partnerships

with Northern links, as well as

partnerships that integrate research,

service delivery, and training and

capacity development as they represent

the most sustainable and equitable type

of institutional partnership.

• There is a need for clearer terminology

relating to partnerships.

• There is a need for a forum to

facilitate better links between existing

networks and to allow institutions and

partnerships to share information and

experiences. Networking organisations

such as EAGHA and CUGH could play this

role.

20


21

3 BENEFITS OF AND CHALLENGES TO INSTITUTIONAL PARTNERSHIPS

3 Benefits of and challenges to institutional partnerships

3.1 Introduction

This chapter considers the benefits of and

challenges to institutional partnerships.

Two challenges that received particular

attention are the difficulty in establishing

equitable partnerships, and governance

issues with multiple partnerships.

3.2 Benefits

Participants outlined the wide range of benefits

for the Northern and Southern institutions, which

are summarised in Box 3.1 and detailed in Annex

VI. It was widely agreed that for partnerships to

be sustainable benefits needed to be experienced

by all partners.

3.3 Challenges

Although partnerships offer substantial benefits,

they are also accompanied by potential

disadvantages and challenges, which multiply

with the number of partners involved and as

the alliance becomes more complex. Box 3.2

outlines the major problems with partnerships

encountered by participants at the conference.

The relative advantages and disadvantages

depend on the nature of the partnership and

whether it is at the level of the individual

researcher, institution and consortium

(see Table 2.1.)

Box 3.2 Challenges

• More complex management and decision-making processes.

• Additional workload required to maintain the partnership over and above existing

responsibilities.

• Higher financial costs and difficulty in overhead recovery (see Chapter 5).

• Power imbalance and research agenda dominated by the Northern institution.

• Diversion of staff and resources away from parts of the Southern institution not involved in the

partnership.

• Logistical challenges (visas, international travel, difficulty transporting samples between

countries).

• Tensions due to cultural differences.

• The wider political and social context.

Box 3.1 Benefits

• Greater access to financial resources.

• Better access to scientific resources (laboratories, equipment, expertise) and talent.

• Capacity building for individuals, institutions and national research systems.

• Improved quality, cost efficiency and productivity of research programmes.

• Enhanced research impact.

• Improved institutional profile and esteem.

• Mutual learning and knowledge exchange between partners that may lead to broadened

perspectives and new solutions to key challenges.

• Long-term relationship and continuity that is not dependent on individuals

22

3.4 Achieving equity within partnerships

The substantial economic and scientific

inequalities between countries are often reflected

in the structure of the partnerships between

both researchers and institutions. Inequitable

partnerships can create problems, with the

potential for the wealthier partner to dominate

the research agenda, the decision-making

process and access to funds. This is illustrated by

the substantial difference in overheads received

by institutions in the North and South (see

Chapter 5). Northern researchers frequently take

the lead on publications, often because Southern

researchers are over-stretched. This can lead to

a sense of disenfranchisement with the Southern

partners in some partnerships relegated to

second, third or middle author.

Inequitable partnerships can lead to disputes

over intellectual property and ownership of

results, specimens and equipment. ‘Weaker’

partners may feel frustrated by a relative paucity

of resources and infrastructure relative to the

‘stronger’ partner. A major concern is that

individuals may become isolated from other

researchers in their own institution or national

network when they have access to substantially

greater resources than their peers. Concerns

were raised that memoranda of understanding

too often favour the richer partner and the

nature of the transactions can be unfamiliar

to Southern partners. Collectively this leads

to frustration and fragmentation. Inequalities

can fuel distrust within the local academic

community. This is especially acute when

partnerships are not linked to sustainable local

health service development or do not focus on

local needs. Although inequities can occur within

any geographical framework, they are most

commonly found in North–South partnerships.

However, the rapid but uneven increase in

scientific capability in different countries may

lead to these tensions becoming more apparent

in South–South alliances.29

3.4.1 Principles for equitable partnerships

Many agreed that partners from the South

should have a real voice in partnerships and

that there should be benefits for all those

involved. In particular, Northern partners need

to acknowledge the critical contribution the

Southern partners bring, particularly through

community engagement and the translation

of research into practice and policy. Several

principles of ensuring equitable partnerships at

individual and institutional level were supported,

and include the following:

• Mutual recognition of respective strengths of

various partners.

• Mutual bi-directional learning; and

recognition that Northern partners have

as much to learn from their colleagues

in the South.

• Mutual trust and respect.

• Shared decision making on issues such as

values and purpose, objectives, credit for

achievements, generation of resources,

accountability and joint products.

Key principles highlighted in previous reports on

partnerships are given in Annex V.

3.5 Governance of multiple partnerships

Participants from some major Southern

institutions described being approached by

multiple prospective partners from the North.

Managing multiple partnerships can present

significant challenges including the following:

• Additional workload required to establish and

manage each partnership.

• Creation of parallel systems for managing

different partnerships.

• Establishment of mini-institutions within

an institution that may undermine rather

than strengthen core infrastructure and

institutional growth.

• Duplication and competition for resources.


29 UNESCO (2010). UNESCO science report. http://www.unesco.org/new/en/natural-sciences/science-technology/prospective-studies/unesco-science-report/

23

3 BENEFITS OF AND CHALLENGES TO INSTITUTIONAL PARTNERSHIPS

• Lack of harmonisation of procedures and

governance arrangements.

• Fragmentation of capacity-building efforts.

Several participants expressed a clear preference

for two or three really strong partners that

provide considerable support, rather than

partners who ‘dip and in out and get more out of

it than us’. Another approach was for institutions

to establish partnerships to address specific

issues based on institutional priorities, and for

the number of partnerships to be determined by

the availability and capacity of partners to help

address them.

3.6 Conclusion

Partnerships offer considerable mutual

benefits both to the Northern and Southern

institutions. Key benefits include access

to shared scientific resources, expertise

and ideas; mutual learning and knowledge

exchange; greater access to financial

resources; improved research quality,

productivity and impact; and opportunities

for individual and institutional capacity

building. The greatest challenge to

partnerships, apart from increased

workload and more complex management,

is the power imbalance within partnerships

because of inevitable differences in

available resources and infrastructure

between Northern and Southern

institutions. Inequitable partnerships

remain common and there is a critical need

for this to change. Participants agreed the

following:

• Key principles for achieving more

equitable partnerships are mutual

trust and respect with recognition of

partners respective strengths, mutual

bi-directional learning and shared

decision making.

• The management of multiple

partnerships with an institution

is a further challenge that may

undermine rather than strengthen core

infrastructure and institutional growth.

This requires a clear institutional

strategy and agreed criteria for

selection of partnerships.

24


25

4 EDUCATION, TRAINING AND CAREER DEVELOPMENT

4 Education, training and career development

4.1 Introduction

This chapter focuses on the challenges of and

several approaches to improving individual

training and career development in Southern

institutions. The specific issues of institutional

capacity building and interdisciplinary education

are considered in Chapters 5 and 8.

There was support at the conference for the

principle that excellent well-trained people

are the foundation of any effective research

enterprise or healthcare system. Although much

progress has been made in developing health

professional and research leaders in Southern

institutions, there remains a considerable lack

of capacity. This is a major reason why too little

research is initiated and led by researchers from

the South and there have been too few high-

quality research outputs from these places.

High-quality training and career development

is vital to the desired outcome of a cadre of

Southern researchers who can:

• Execute and lead international level research

and clinical care.

• Define the research agenda for their region.

• Direct local and regional research and health

service capacity building.

• Negotiate with governments for

increased investment in research and in

implementation of research findings.

• Collaborate effectively with international networks.

Training and career development initiatives

also need to take into account the changing

expectations of researchers and healthcare

professionals highlighted in The Lancet

commission ‘Health professionals for a new

century’. This report stressed the need for

increased emphasis on interdisciplinarity, health

systems connectivity, problem-based learning,

national capacity building and international

partnerships.30

4.2 Challenges in Masters and doctoral training

Key challenges for Masters and doctoral students

from Southern institutions that were identified by

participants include the following:

• Weak systems for PhD registration and

support.

• Didactic teaching methods.

• Lack of experienced mentors in PhD

supervision.

• Lack of basic research and technical skills

among some students.

• Limited government funding for training and

research in Southern institutions.

• Limited opportunities for regional or

international co-operation.

• Poor linkages between training and career

development in many of the Southern

institutions.

• That PhD’s are often viewed as an endpoint,

rather than the beginning of a career.

4.3 Challenges in postdoctoral career development

Postdoctoral fellows in the South face

considerable hurdles in sustaining their training

and career development. Once they have

finished their PhD, researchers frequently find

themselves without a desk, IT access, research

funding, laboratories or mentorship. The lack of

research-oriented career paths and flexibility to

employ scientists on fixed-term contracts using

‘soft’ money means that PhDs at many Southern

institutions are often appointed as lecturers soon

after receiving their PhDs. This means that they

then need to balance the competing demands

of heavy teaching and/or clinical work with

consolidating their research programme. These

factors, together with ill-defined career paths,

limited job security and poor pay, contribute to

a high attrition rate. Many researchers from the

30 Frenk, et al. (2011). Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. http://www.caipe.org.uk/silo/files/health-professionals-for-a-new-century.pdf

26


South emigrate for better paid, better structured

jobs elsewhere, often to those countries in

the North where they received education and

training. A further driver to migration is the

mismatch between skills acquired and limited

opportunities upon returning home.

Several leaders of Southern institutions

highlighted the need for change or at least

flexibility in the rigid career structures within

African and Asian institutions and for the

establishment of postdoctoral positions with

protected time and administrative support in the

university structure.

4.4 Strategies to improve doctoral training and postdoctoral career development

4.4.1 Joint or sandwich PhD and

postdoctoral programmes

Several types of partnership-led training

programmes were considered at the conference,

including the following:

• Access to research degrees and training in

Northern institutions.

• Joint or sandwich PhD programmes between

Northern and Southern institutions.

• Short-term overseas attachments for specific

skills training.

• Short visits or staff exchanges.

• Informal mentoring and mentorship training.

Sandwich or joint PhD schemes vary from a few

months at the Northern institution to a full year.

Examples raised at the conference include the

following programmes:

• The University of Malawi/Liverpool

University.

• Public Health Foundation of India.

• Makerere University and Karolinska Institute

scheme (detailed in Box 4.1).

Box 4.1: Makerere University and Karolinska Institute sandwich PhD and postdoctoral programme

This collaboration started in 2001 with the Swedish International Development Agency (SIDA)

funding twinning supervisors in five research areas with 20 PhD students. It has subsequently

expanded to cover more students and more areas of research.

The scheme involves joint supervision by faculty at Makerere University, the Karolinska Institute

and other universities in one of over seven areas of research. Students are awarded a joint PhD

degree between Makerere University and Karolinska Institute, the first being in June 2005.

The collaboration has grown to include teacher and student exchange, and has attracted several

research grants beyond the initial SIDA funding. The collaboration is now being developed towards

a long-term university partnership.

In 2001, a sandwich programme for postdoctoral fellows was also developed as part of the

Makerere University and Karolinska Institute collaboration, as well as a joint course on leading

change in education of health professions at both institutions.

Further details are available from http://ki.se/ki/jsp/polopoly.jsp?d=38539&a=2477&l=en

27


A further variant on the sandwich programme

is the pan-African INDEPTH network

capacity-building Masters programme in

field epidemiology in collaboration with Wits

University in South Africa. As part of this

programme, MSc students undertake their

research work at several field sites outside their

own country.

At postgraduate level, a one-year overseas

training placement is offered by the Post-

Graduate Institute of Medicine (PGIM) training

scheme in microbiology and parasitology at the

University of Colombo, Sri Lanka.31 Specific

challenges encountered in this programme

include higher costs, difficulties in finding

overseas training placements and obtaining

visas, lack of opportunities for non-medical

trainees and a high attrition rate.

Such partnership-led training programmes offer

those involved considerable mutual benefits and

opportunities. For example, less experienced

partners benefit from the credibility of an

established partner’s academic programme,

whereas stronger Northern partners benefit from

the kudos, and the skills and local knowledge of

their partners.

There was an increasing recognition of the

need to establish locally owned in-country

Masters level and doctoral level programmes, as

illustrated by the recently established Masters

in Public Health programme at the University

of Malawi, with programme development and

faculty joint with external research partners.

4.4.2 PhD finishing schools and re-entry

incentive schemes

‘PhD finishing schools’ that offer institutional

links, IT, mentorship and grant-writing and

advocacy skills were proposed as another

potentially useful approach to help develop

the careers of postdoctoral fellows and retain

them in research in their home country. Some

relevant initiatives already exist. For example,

the Consortium for Advanced Research Training

in Africa (CARTA) offers a series of seminars

aimed at helping PhD students find postdoctoral

fellowships.32 Re-entry incentive schemes are

also being undertaken by organisations such

as the Gates Malaria Partnership, Gates Malaria

Capacity Development Consortium, Special

Programme for Research and Training in Tropical

Diseases (TDR) and the Public Health Foundation

of India.33 The University of Malawi’s joint

PhD programme with Liverpool University also

provides a re-entry incentive scheme, including

ethics training, paper- and grant-writing skills,

and IT support. Another helpful resource

for postdoctoral students returning home is

‘Excellence everywhere’, a handbook produced

by the Burroughs Wellcome Fund.34

4.4.3 Enhancing retention through social

business models

Much can be learnt about retention of skilled

staff from social business models, such as

the Grameen Bank-funded Bangladeshi nurse

training scheme that offers well paid, guaranteed

jobs in exchange for career development

opportunities and interest-free loans (see

Box 6.1). Another example comes from the

Philippines where most local health professionals

emigrate. Here a tripartite model sees villagers

support the medical training of local students

at the University of the Philippines. The scheme

guarantees graduates a local job, and if endorsed

by the community, a chance to gain further

qualifications. In operation since 1976, this

particular model has been a notable success:

90% of programme graduates stay working

within the Philippines and infant mortality rates

have dropped.

31 Further details as the PGIM can be found at http://www.cmb.ac.lk/pgim/32 Further information is available from http://www.aphrc.org/insidepage/?articleid=417 33 Further details of the Malaria Capacity Development re-entry scheme can be found at

http://www.mcdconsortium.org/phd-programme/re-entry-grants.php 34 Burroughs Wellcome Fund (2009). Excellence everywhere. http://www.excellenceeverywhere.org/images/book/excellence_everywhere.pdf

28

4.4.4 Distance learning and mobile

technologies

Improved communications have catalysed the

use of electronic, mobile and distance learning as

part of global health partnerships. One approach

pioneered by the London School of Hygiene

and Tropical Medicine has been to license their

distance learning material to institutions in

low-income countries to adapt and use as

they wish. This has helped institutions like

the University of Ghana to start new courses

without the extensive preparatory work involved

in generating new teaching materials. Other

examples include the following:

• Kenyan nurses obtaining their course notes

and answers to questions by mobile phone

to enable them to upgrade from certificate to

diploma level.

• Online interdisciplinary distance learning

programmes at the University of Edinburgh

Global Health Academy (see Chapter 8).35

Difficulties inherent in the delivery of distance

learning material in resource-poor countries


• Limited bandwidth that makes the download

of complex images slow.

• Inadequate IT support locally.

• Unreliable cost and supply of electricity.

Despite the success of these approaches some

individuals highlighted the specific benefits of

overseas training at another institution that

would not be obtained from e-learning alone.

These included the following:

• Direct observation and experience of

organising research.

• Effective collaboration between the

university and local public health

department.

• The opportunities presented by analysis of

electronic medical records.

4.5 Regional networks

The increasing importance of regional

co-operation in both training and research was

highlighted at the conference. Examples included

the following:

• Two major externally funded partnership

projects of the Indian Institute of Public

Health: the South Asian Network on Chronic

Diseases, funded by the Wellcome Trust and

the Centre of Excellence for Chronic Disease

Prevention Control, across India, Pakistan,

Bangladesh and Sri Lanka, funded through

an NIH grant.36

• The Association of Public Health in Africa,

which aims to link universities and schools

of public health, as well as public health

researchers and specialists to develop an

environment for improved public health

training together. A major limitation

continues to be the shortage of funds for

regional travel and networking.

• The PHFI has established a web portal for

linking up many institutions in low- and

middle-income countries to share resources.

Additional distance learning programmes in

epidemiology, public health nutrition, health

promotion and research methodology are

also offered.

• In Latin America, a Masters programme

in public health and biomedical sciences,

organised by the CPLP comprises eight

countries and four continents (South

America, Portugal, five countries in Africa

and East Timor in Asia), is stationed at the

Mozambique National Institute of Health

and in Angola.


35 Further details can be found at http://www.ed.ac.uk/schools-departments/global-health36 Further details of the South Asian Network for Chronic Disease can be found at http://www.sancd.org/

29


4.6 Training the trainers

A significant educational challenge is that many

of those from the South who train others in

biomedical and health research have themselves

had inadequate formal training in teaching.

To this end, the West African Biomedical

Education Network, a partnership of African and

British universities and professional societies,

offers a two-year part-time modular MSc course

for biomedical teachers in six West African

universities.37 Participants continue teaching in

their home institutions, while using e-learning to

complete a programme that includes curriculum

design, assessments and exams, and quality

assurance. The scheme makes use of expertise

from two Northern universities, Liverpool and

Swansea, and the regional postgraduate colleges

of the West African College of Physicians and

Surgeons. The United Nations of the South

and the Community of Lusophonic Countries

have tackled the same problem by developing

an innovative ‘training the trainers’ rotational

programme, whereby those from technical

schools train teachers from partner countries

(see Box 2.2).

Specific challenges reported are the differing

regulations between institutions and countries,

poor IT and communications infrastructure in

partner institutions, insufficient number of trained

medical educators to serve as tutors, and the

need for extensive, expensive travel within the

region to mobilise support. The sustainability of

such programmes requires a demonstration that

course graduates are more effective teachers.

4.7 Strengthening pre-university education systems

Although the conference focused on higher

education and career development, the

importance of enhancing earlier stages of science

education was recognised. Without strong

primary and secondary education systems there

will not be a pipeline of individuals to undertake

higher education and research. Although

there are models of excellence, participants

commented on the persistence of didactic

teaching methods. Schoolchildren need to be

instilled with excitement about science through

a more problem-based approach to teaching,

exposure to hands on experimentation,

or internships in research programmes for

pre-university students.38

4.8 Engaging diasporas

The diaspora of trained researchers from the

South who have settled in the North can also

make a potentially valuable contribution to

training in their country of birth. Although many

such migrants may not plan to return home

permanently, Southern institutions need to be

creative about arrangements and conditions

to encourage them to return home for short

periods to help with teaching and in establishing

institutional links. This has been successfully

achieved by several Chinese institutions, and

other countries might learn much from their

experience.39

37 Further details are available from http://acp-edulink.eu/content/teaching-skills-west-african-medical-and-nursing-schools38 Whitworth J, Sewankambo N & Snewin V (2010). Improving implementation: building research capacity in maternal, neonatal, and child health

in Africa. PLoS Medicine. 7(7), e1000299.39 Wilsdon J & Keeley J (2007). China: the next science superpower. http://www.demos.co.uk/files/China_Final.pdf?1240939425

30


4.9 Building global health into UK medical education and careers

Barriers to global health education, training and

career development that impede partnerships

and capacity building exist in the North as well

as the South. In the UK, some of these hurdles

concern the constraints and requirements of

training programmes, rather than the lack of

funding or resources. For example, concerns

were raised about the increasingly inflexible

approach to postgraduate medical trainees taking

time out of their programmes to work abroad.

4.10 Conclusion

Doctoral and postdoctoral training in

Southern institutions continues to be

challenged by lack of capacity in skilled

mentorship, limited research-oriented

career pathways, and poor institutional

infrastructure and support. A major priority

identified at the conference was the need

for additional support from Southern

institutions and funders for postdoctoral

researchers from the South. Proposals

included the following:

• PhD ‘finishing schools’ to develop

further the skills of PhDs in grant and

manuscript writing, IT, management

and leadership skills and building

networks.

• Expansion of career development

and re-entry fellowships incentive

schemes to encourage PhD graduates

to undertake postdoctoral work in their

home country.

• The need for Southern institutions to

provide a supportive environment and

introduce more flexibility into their

career structure through protected

research time and administrative

support.

• Measures to ‘train the trainers’

including courses in mentorship

and shared supervision, mentorship

between faculty across Southern and

Northern institutions, and student and

faculty exchanges using regional

South–South and South–North

networks.

Other opportunities to improve education,

training and career development include

the following:

• Expansion of the successful model of

sandwich and joint PhDs, and short

overseas placements.

• Greater development of electronic and

distance learning, particularly through

Northern institutions facilitating

affordable access to their distance

learning materials.

• Additional piloting and evaluation of

sustainable financing mechanisms for

training, such as the social business

model.

• Engaging diasporas to support training

in their home country.

• Support for early development

of interest in science through for

secondary school students.

31

5 BUILDING INSTITUTIONAL CAPACITY

5 Building institutional capacity

5.1 Introduction

Although many successful global health

partnerships are driven by relationships between

individuals, academic institutions must also be

able to provide the necessary infrastructure

and support. Participants noted that previously

partnerships have focused largely on individual

capacity development and neglected the

essential institutional and non-academic

structures and capacity. This includes areas such

as the following:

• Financial management.

• Human resources and staff development.

• Contract negotiation.

• Grants administration.

• Ethics procedures.

• Intellectual property management.

• IT and data management.

• Degree administration and quality

assessment.

• Legal and regulatory frameworks.

More recent partnership initiatives are beginning

to tackle these issues and to integrate individual

with institutional development. Examples include

the following:40,41,42,43

• The Maastricht University Centre for

International Cooperation in Academic

Development (MUNDO).

• The Malaria Capacity Development

Consortium.

• EDCTP Networks of Excellence in Clinical

Trials (see Box 7.1).

• The Wellcome Trust African Institutions

Initiative (see Box 2.2).

5.2 Financial and research administration and infrastructure

A major challenge for global health partnerships

and capacity building raised at the conference

is the limited capacity and weak infrastructure

in research management and financial

administration in Southern institutions. In taking

forward their pioneering work to build research

capacity in Africa through the African Institutions

Initiative, the Wellcome Trust found that most

institutions had limited experience of grants and

research management, as well as weak financial

planning and audit. These weaknesses placed a

high management load on the Wellcome Trust.

The need for greater financial management

capacity in partnerships was illustrated by

one participant who needed over 350 receipts

processed and accounted for after a single

three-month trip to Bangladesh.

Limited administrative capacity is further

exacerbated by high staff turnover in areas

such as finance and human resources.

Several participants reported the experience

of administrative staff trained in Southern

institutions promptly leaving for the private

sector, which offers greater financial rewards.

This creates gaps in the institutional memory,

making good record keeping and development

of standard operating procedures even more

important. An additional challenge is the

tendency of North–South partnerships to

establish their own parallel administrative

structures to circumvent central institutional

bureaucracies perceived as too cumbersome.44

Although this practice may improve efficiency

in the short-term, it undermines local capacity.

Instead, greater efforts should be made to build

Southern administrative capacity.

40 Further details of MUNDO can be found at http://www.maastrichtuniversity.nl/web/show/id=1131643/langid=42/ 41 Further details of the Malaria Capacity Development Consortium can be found at http://www.mcdconsortium.org/ 42 Further details of the EDCTP Networks of Excellence in Clinical Trials are available from

http://www.edctp.org/Networks_of_Excellence.641.0.html43 Further details of the Wellcome Trust African Institutions Initiative are available from

http://www.wellcome.ac.uk/Funding/Biomedical-science/Funding-schemes/Strategic-awards-and-initiatives/WTD028338.htm44 Crane J (2010). Scrambling for Africa? Universities and global health. The Lancet 377(9775), 1388-1390.

32


The establishment of research support centres

that assist with matters such as budgetary

review, contract negotiation, grant writing

and ethics was one strategy identified at the

conference to help build institutional capacity.

For example, the University of Malawi has

established such an office that helps with these

tasks, as well as disseminating research calls

from external funders, providing standard

operating procedures on how to submit projects

and helping researchers to get the best out of

awards letters.45 The office is now beginning to

put together a data management system with

standard operating procedures that adhere to

international standards.

5.3 Overhead recovery

The funding available for research, including that

conducted by global health partnerships, can

broadly be divided into two categories: funding

for direct costs such as staff and equipment,

and indirect costs or overheads taken as a

percentage of the overall grant for maintenance

of buildings and equipment, grants management

and human resources. Overhead recovery

should be an important source of longer-term

investment into improving university structures

but is a particular challenge for institutions in the

South. This is because science budgets in poorer

countries often do not cover many essential

costs, and Southern institutions receive a much

smaller proportion of the total grant as indirect

overheads (typically less than 10%) compared

with institutions in the North (up to or in excess

of 50%). When coupled with limited institutional

support from Southern governments, global

health partnerships may weaken institutions in

the South if limited central funds are diverted to

maintain the partnership infrastructure. Many

participants agreed that a greater proportion of

Southern infrastructural costs may need to be

covered either through improved direct support

for institutions or a more equitable distribution

of the overhead allocation to the Southern

institution.

An inadequate allocation of overheads can also

create challenges for institutions in the North,

where it is sometimes perceived that they are

effectively subsidising Southern institutions

through their partnerships. Such a financial drain

can be a major disincentive for universities to

engage in partnerships, and for vice chancellors

to limit the number of partnerships, especially in

the case of smaller organisations.

5.4 Faculty development

Academics are not usually trained or selected

for their broader leadership skills until they

reach senior positions. This contrasts with the

experience in industry, where staff are selected

for a management track much earlier in their

careers, and given an important foundation in

areas such as governance, health and safety,

and financial management. This deficiency

applies to institutions in both the North and

South; however, at Northern institutions,

faculty development and leadership and

management training programmes are now

becoming more commonplace. Although it was

acknowledged that not all leadership skills can

be taught, many participants endorsed the

value of core management training in budget

management, mentoring and appraising staff,

personnel management, and time and project

management. An example involves senior

administrators from Liverpool University who are

working with researchers at Malawi University to

share skills, giving both partners the opportunity

to learn about leadership and governance issues.

Another concern raised at the conference is that

women remain poorly represented in the upper

echelons of institutions and in global health

research, policymaking and management in both

the North and South. The under–representation

of women in leadership roles means a

considerable pool of potential talent is not being

used, and that there are few role models or

mentors for talented young female researchers.

45 Further details of the Research Support Centre at the University of Malawi College of Medicine can be found at http://www.medcol.mw/rsc/

33

5 BUILDING INSTITUTIONAL CAPACITY

5.5 Engaging senior management

High-level institutional buy-in was identified

by participants as a major ingredient in the

success of global health partnerships that allows

institutions to take a more strategic approach.

The support of deans and vice chancellors is

particularly important as the time and energy

required to conduct global health research

through partnerships may come at the expense

of teaching or service delivery. This is particularly

relevant to staff appraisal and promotion, where

partnership activities may be less well regarded

and rewarded than the more traditional outputs

of publications and grants.

Of particular value is a champion at the executive

level within the institutional hierarchy who

recognises (in the case of a Northern university)

that international activity goes beyond

attracting fees from foreign students, and

who can advocate for the value of institutional

partnerships. Several Southern institutions

such as Makerere University, the University

of Nairobi, the University of Ghana and the

College of Medicine in Malawi have established

positions of deputy vice chancellor of research

and development, and there is an expectation

that these roles will help place institutional

partnerships for capacity building and research

higher in the institutional agenda.

Even when there is institutional buy-in, the

turnover of senior staff means that it can swiftly

be lost. Deans of postgraduate and research

studies have limited terms of office.

5.6 Local and national governance

Good governance is essential if efforts to build

partnerships and capacity at both the individual

and institutional level are to be successful.

Strong steering committees or management

boards need to be set up early on to help

establish a mutually agreed research agenda

and monitor outcomes. All partners need to

assess the institutional capacity requirements

and gaps at the beginning of their relationship,

and to establish explicit agreement on legal

and ethical frameworks and consensus on

budget and resource allocation. Methods to

facilitate the dissemination of research, such

as conferences, newsletters and paper-writing

skills, are also needed.

The experience of participants was that high

levels of local involvement in the daily running

of partnerships enable them to operate

smoothly. Governance structures need to

be explicit, transparent, flexible and able to

respond to emerging requirements. Documents

such as memoranda of understanding and

standard operating procedures are useful to

promote clarity in these arrangements, and to

frame and record governance structures. It was

also noted that often partnerships do not have

their own legal status. This can mean that some

of the legal liabilities fall on individuals rather

than the institution. Such legal inconsistencies

need to be addressed and built into the

governance structure of partnerships, ideally at

the design stage.

Governance also needs to be strengthened at

the national level. Legislation in many African

countries, for example, needs to be modernised

to protect intellectual property rights, facilitate

the exchange of materials and data, and

support the conduct of research.46 In addition,

governments need to support research by

strengthening research governance frameworks

nationally and providing strategic planning for

health service development.

Participants highlighted several recently

established funding schemes that offer financial

support to improve governance and research

management. The EDTCP is helping to foster

partnerships and build capacity by creating an

enabling environment for the conduct of clinical

trials through support of regulatory framework,

46 Whitworth J, Sewankambo N & Snewin V (2010). Improving implementation: building research capacity in maternal, neonatal, and child health in Africa. PLoS Medicine 7(7), e1000299.

34


47 Further details are available from http://www.pactr.org/48 Further details are available from http://www.edctp.org/ and http://www.nwo.nl/nwohome.nsf/pages/NWOP_5VWBMM_Eng

ethics committees, and support for the Pan

African Clinical Trials Registry (PACTR).47 Another

example is the Netherlands-African Partnership

for Capacity Development (NACCAP).48 However,

the general experience was that it is difficult to

obtain funding for this sort of activity.

5.7 Integrated solutions

Institutional capacity building may require multiple

approaches. This multi-pronged approach to

specific institutional infrastructural challenges has

been the strategy of the College of Medicine at the

University of Malawi, detailed in Table 5.1.

Challenges Solutions

1. Weak research co-ordination. 1. Establishment of a Research Support Centre.

2. Research policy implemented through

guidelines and standard operating procedures.

2. Weak research administration. 1. Grant management positions created in the

Research Support Centre.

2. Grants management training through

organisations such as European and

Developing Countries Clinical Trials

Partnership (EDCTP).

3. Clinical Trial Support Services.

3. Ineffective dissemination of research

findings;weakcommunicationsdepartment.

1. Annual research dissemination conference.

2. Quarterly newsletters.

5.8 Conclusion

Development of institutional infrastructure

and governance to address the limited

capacity and weak infrastructure in

research and financial management has

been a neglected area of capacity building.

Funders and Southern governments should

direct more resource to the building of

institutional capacity, whereas Northern

institutions can provide support through

sharing of systems and expertise. Priority

areas for development include the following:

• Establishing central research support

centres for research management

within institutions.

• Progressive integration of grants and

financial management of existing

North–South partnerships into central

university infrastructures.

• Ensuring a more equitable and

transparent arrangement for

distribution of overheads between

Southern and Northern institutional

partners to support infrastructure.

• Providing faculty management training

earlier in the career path, in areas such

as financial and personnel management,

and leadership development.

• Creating advocates for global health

partnerships and capacity building at

senior positions within institutions.

• Developing institutional and national

policies on the legal and ethical

framework for partnerships, intellectual

property and transfer of samples.

• Ensuring Northern universities

recognise and support activities of their

staff engaged in international capacity-

building work in Southern institutions.

Table 5.1 The College of Medicine at the University of Malawi’s approach to institutional capacity building

35

6 FUNDING AND SUSTAINABILITY

6 Funding and sustainability

6.1 Introduction

Participants at the conference heard that over

the past 30 years global health has experienced

substantial and increasing levels of funding from

a wide range of sources.49 Major funders, such

as the World Bank and the Global Fund, have

donated tens of billions of dollars, enabling many

countries to achieve remarkable results, whereas

the GAVI Alliance has transformed the way global

health is financed and delivered.

However, there are some recent worrying trends.

First, not surprisingly given the global economic

downturn, the rate of growth in global health

funding is declining. In 2007 the annual growth

rate of global health expenditure was around

17% but by 2010 it had fallen to 6%.50 Second,

the United Nations system is becoming an

increasingly smaller component of that spend,

raising concerns about the future of multilateral

institutions. Specifically WHO is experiencing

financial difficulties with budget cuts and closure

of some of its programmes as part of its reform

agenda. Third, the Global Funding of Innovation

of Neglected Diseases (G-Finder) report showed

that although there has been an overall modest

increase in research for global health, most has

been for basic research.51

6.2 Funding for partnerships

Currently only a small fraction of scientific funding

is devoted to encouraging international scientific

collaboration through partnerships, indicating

that policymakers have not always recognised

the importance of these linkages.52 However, a

series of new funding initiatives specifically for

partnerships have been developed that include

EDCTP, the Wellcome Trust African Initiatives,

NIH/Fogarty funded MEPI and the Doris Duke

Foundation partnerships scheme.53,54,55,56

Bilateral funding agencies, such as the

Department for International Development

(DfID), United States Agency for International

Development (USAID) and the Australian Agency

for International Development (AusAID), can

bring much more than money to partnerships

through their access to policymakers and cross-

and inter-governmental networks. The limitations

of their financial support include a shorter-term

budgetary and political cycle, with the need

to demonstrate results relatively quickly, and

changing government priorities – a problem for

long-term relationships, and the constraints of

the donor’s agenda. This has led to the view that

it is preferable for bilateral agencies to invest

through multilateral vehicles like TDR or Global

Fund, so that if one donor pulls out, the activity

can be maintained.

One concern raised at the meeting was the

lack of funding to support those aspects of

partnership activity that are performed by

institutions in the North. Although funders

are often prepared to support core activities

in Southern countries, they are less willing to

support the collaborative supporting activities of

staff in the Northern institutions.

6.3 Engaging Southern funders

Funding for capacity building and partnerships

need to be diversified beyond the usual

international foundations and agencies.57

49 Murray CJL, et al. (2011). Development assistance for health: trends and prospects. The Lancet 378(9785), 8–1050 Murray CJL, et al. (2011). Development assistance for health: trends and prospects. The Lancet 378(9785), 8–1051 George Institute (2009). Global funding of innovation for neglected diseases: G finder. George Institute, Sydney, Australia52 The Royal Society (2011). Knowledge, networks and nations. http://royalsociety.org/policy/reports/knowledge-networks-nations/53 Further information on the EDTCP is available from http://www.edctp.org/54 Further information on the Wellcome Trust African Institutions Initiative is available from

http://www.wellcome.ac.uk/Funding/Biomedical-science/Funding-schemes/Strategic-awards-and-initiatives/WTD028338.htm 55 Further information on the NIH/Fogarty funded MEPI is available from http://www.fic.nih.gov/Programs/Pages/medical-education-africa.aspx 56 Further information is available at http://www.ddcf.org/Medical-Research/Program-Strategies/African-Health-Research/57 Whitworth J, Sewankambo NK & Snewin VA (2010). Improving implementation: building research capacity in maternal, neonatal and child

health in Africa. PLoS Medicine 7(7), e1000299.

36


Although some countries such as South Africa,

Kenya and Egypt are beginning to provide

government funding for academic institutions

and research in the South, many conference

participants considered that there was

insufficient Southern support with most African

R&D being funded through external sources.

Southern governments, philanthropists, private

and business sectors, faith-based organisations,

civil society and NGOs represent a large and

as yet relatively untapped source of funding.

For example, India is home to 55 US dollar

billionaires, Africa is home to 20 US dollar

billionaires and many Southern countries such

as India, Brazil and China are experiencing

rapid economic growth.58,59 Yet at present

Southern philanthropic and private sector

investment is low.60,61 This current lack of

Southern funding contributes to North–South

partnership inequities, skewing ownership and

research agendas.

There is, however, encouraging evidence of

change, with some government ministers

beginning to show an interest in global health

partnerships and capacity building, and several

initiatives outlined below.

• For the past 10 years in Ghana, 2.5% of VAT

has gone towards the Ghana Educational

Trust Fund (GET). This now represents a

substantial resource, although so far none

of the money has been earmarked for

research.62

• Philanthropic and private sector investment,

although scarce, is becoming more common.

One speaker highlighted several examples

of wealthy Africans putting resources into

medical research, notably in Nigeria.

• Local Southern businesses are increasingly

investing in building health capacity through

corporate ‘social responsibility’ funds such as

that provided by the Kenyan EQUITY bank,

which sponsors and employs top high-school

students before entrance to university.63 It

is likely that similar organisations can also

be persuaded to invest in health and national

governments could help incentivise this sort

of activity.

• The African Network for Drugs and

Diagnostics Innovation (ANDi) was launched

in 2008 to promote and support health

product R&D led by African institutions for

diseases that are highly prevalent in the

continent.64 Two key features of ANDI are

efforts to engage the private sector and

the direct involvement of Ministers from

South Africa, Egypt, Kenya and Nigeria. The

performance and impact of this and other

similar models will need careful evaluation

over the coming years to determine whether

this is an approach that should be more

widely replicated.

• Endowment funds are beginning to emerge,

although are still rare in Africa because

of funders’ regulations on how money

can be spent. A notable example is the

African Science, Technology and Innovation

Endowment Fund (ASTIEF), established

by United Nations Economic Commission

for Africa (UNECA) that aims to fund and

support both enterprising individuals

and African R&D centres. So far several

business leaders, firms and institutions

have contributed to the fund, including

UNECA and the African Business Round

Table. In addition President Kagame of

Rwanda, a strong supporter of science and

technology, is keen to establish this kind of

an endowment fund to tackle some of the

health challenges in his country.

6.4 Long-term sustainability

Successful global health partnerships are usually

long-term endeavours that require significant

58 Forbes (2011). The worlds billionaires. http://www.forbes.com/wealth/billionaires 59 Economist (2011). Outputs, prices and jobs. http://www.economist.com/node/21524899 60 Forbes (2011). The worlds billionaires. http://www.forbes.com/wealth/billionaires 61 Economist (2011). Outputs, prices and jobs. http://www.economist.com/node/21524899 62 Further information is available from http://www.gra.gov.gh/docs/info/ge_trust_fund_act.pdf 63 Further information about the educational work of the Kenyan Equity bank can be found at http://www.equitybank.co.ke/about.php?subcat=964 Further information about ANDI is available from http://www.andi-africa.org/

37

6 FUNDING AND SUSTAINABILITY

funding over long periods. Key challenges

to sustainability identified at the conference


• The capacity-building component of

partnerships is often undertaken off the back

of existing project and programme funding.

• Difficulty in obtaining funding for partnerships

that only involve institutions from the South.

• Funding streams typically last only three to

five years.

• Short-term budgetary cycles of government and

business and rapid turnover of ministers and

CEOs relative to long-term global health goals.

Several strategies to address these challenges

are outlined below.

6.4.1 Longer-term funding

Longer-term, more flexible core funding allows

investigators to tackle areas that present higher

risk but potentially greater reward. One example

is an NIH-funded scheme that provides funding

for up to seven years through its International

Centres for Malaria Research (ICEMR) scheme.65

Long-term funding does not have to come from

the same source. Indeed, if funders continue to

support one particular initiative, they would not be

able to fund new programmes. Risk assessments

of funding need to be conducted early in the

development of global health partnerships to plan

a sustainable funding strategy.

6.4.2 Social business model

Social businesses, such as the Grameen Bank-funded

Bangladeshi Nurse Training detailed in Box 6.1,

offer another more sustainable model of funding.

This approach is based on the philosophy that no

institution dealing with local community problems

and health issues should be reliant on external aid.

Social businesses are less reliant on intermittent

and changing donor funding as they are non-loss,

non-dividend companies that generate a modest

profit for reinvestment. Another similar sort of

approach has been undertaken at the University

of the Philippines and is detailed in section 4.4.3.

65 Further details can be found at http://www.niaid.nih.gov/LabsAndResources/resources/icemr/Pages/programOverview.aspx

Box 6.1: Training nurses in Bangladesh: a model of sustainability?

In 2009, a new partnership offering young, rural women the opportunity to train as nurses was

established in Bangladesh. This not-for-profit scheme offers women from Grameen Bank borrower

families a four-year interest-free loan to cover training fees, accommodation and living expenses

while they complete nursing training. Newly trained nurses are guaranteed a job with the Grameen

organisation on the same pay as doctors, and after a year’s grace, the loan is paid back at

5% interest. At present, there are over 70 students and the income generated represents just

25% of overall costs. It is estimated that 600 nurses will need to be enrolled to achieve full

sustainability and it is thought this will happen by 2014.

The programme, which aims to help break the cycle of poverty for women, is a three-way partnership

between the Grameen Healthcare Trust, Glasgow Caledonian University and the NIKE Foundation. The

partnership strives to balance vision from the South with leadership from the North, and has created

role models, a new curriculum, a permanent college and living accommodation for the students.

But it does far more than just train nurses. The scheme empowers women to become leaders and

agents of change, capable of influencing global health on many different levels. And it highlights the

possibilities of social business models to promote sustainable, capacity-building endeavours.

Further details of this initiative are available from

http://www.gcu.ac.uk/grameencaledonianpartnership/

38


6.4.3 Overhead sharing and recovery

The challenge of the lower rate of overhead

recovery for institutions in the South compared

with those in the developed world has been

discussed in Chapter 5. Achieving long-term

institutional capacity strengthening will require

the more effective sharing and disbursement of

project or research grant overheads.

6.4.4 Engagement with national

governments and links to policy generation

Governments have to make hard choices about

where to spend limited tax revenues. A decision

to invest in global health partnerships, rather

than education or transport infrastructure,

requires evidence from evaluations, which

are often lacking. Participants noted that it

is the public and researchers from Southern

countries who are best placed to engage and

lobby Southern governments and other potential

funders. This is discussed further in Chapter 7.

Several examples were presented at the

conference of how effective engagement with

national government and policy generation

had sustained the partnership and had other

secondary benefits. For example, the activities

of the ‘One Health’ programme (see section

8.1) has been incorporated into the Ugandan

governments five-year plan ‘Prosperity for all’. A

recent Palestinian national health strategy was

developed and shaped through a longstanding

fifteen year partnership between the University

of Oslo, the departments of medicine and public

health at Birzeit University and the local public

health community. Similarly, the partnership

between the University of Washington Global

Health program and Washington State has

been boosted by the clear demonstration of the

contribution made by global health work of the

university to job creation and the state economy.

6.5 Conclusion

The most successful partnerships are

long-term endeavours that require

sustained core funding. With the global

economic downturn and slowdown in

global health funding, sustainable funding

for partnerships and capacity building

needs to diversify beyond the traditional

dependence on external agencies. Southern

governments, Southern funders and

Southern philanthropists are not yet fully

engaged with global health partnerships

and capacity building by demonstrating

the direct benefits of partnerships.

Researchers, universities and funders

should encourage those from the South to

invest in sustainable global health research

partnerships that build research capacity.

Key proposals discussed at the meeting


• The more equitable sharing of

overheads between Northern and

Southern partners.

• The use of Southern government

tax revenue for health research and

capacity building.

• Engagement with local business

corporate social responsibility funds,

philanthropic funds and public-private

partnerships.

• Strategies for more sustainable funding

include longer-term project funding

schemes as partnerships take time to

produce results, a social business model

for training initiatives and development

of institutional endowment funds.

39

7 Evaluation of partnerships

7.1 Introduction

Not all partnerships are equally successful.

Evaluation offers an opportunity to find out

why and is an essential part of developing best

practice. With the establishment of so many

institutional partnerships over the past 10 years

there is a pressing need to evaluate whether

their research, service or capacity-building

goals have been achieved, and to share learning

from these experiences, using robust and

generalisable methods.66 However, the literature

is sparse and there are relatively few examples of

well-designed evaluations. Too often, evaluation

is added in as an afterthought when funds and

resources are already stretched.

It is important to note that monitoring

and evaluation represent two distinct

but inter-related activities. The focus at

the conference was on evaluation rather

than monitoring.

7.2 Challenges to building the science of evaluation

Evaluation is a relatively new science that

requires a rigorous experimental approach.

Dissatisfaction was expressed at the meeting

with existing approaches and several key

challenges were identified:

• A weak evidence base; evaluations of

‘real-life’ capacity development interventions

are almost non-existent.

• Those studies that do exist often lack

methodological rigor with the use of

non-validated tools, limited pilot testing of

existing tools and indicators, retrospective

data collection and biased sampling.

• Most current indicators are perceived as too

broad, lack specificity for the programme

objectives and are focused on quantitative

measures only, such as the number of

publications or PhDs.

• Poor integration between quantitative and

qualitative methodologies.

• Lack of a common language to describe the

science of evaluation.

• Lack of experts (capacity) in evaluation

science, particularly in the South, resulting

in partners from the North undertaking most

of the work.

• The widely held view that evaluation

research is both hard to fund and publish

because it often does not involve rigorous

randomised controlled trials.

These challenges are illustrated by a systematic

review of the capacity-building literature in

2010 that identified 593 potentially relevant

evaluations, of which only 31 were primary

research studies that used acceptable

methodology, and only four were from low- and

middle-income countries.67

Yet, funding for evaluation is available, especially

from larger funders who may incorporate

evaluation as a prerequisite for funding. The NIH,

for example, allocates around 1% of its budget

to evaluation; the Global Fund recommends

grantees set aside 5-10% of their budgets

for evaluation and monitoring, although the

resources available to this organisation are

increasingly constrained.

66 Whitworth J, Sewankambo N & Snewin V (2010). Improving implementation: building research capacity in maternal, neonatal, and child health in Africa. PLoS Medicine 7(7), e1000299

67 Cole D, et al. (2011) Searching for Evidence on Effectiveness of Health Research Capacity Development initiatives with Lower and Middle Income Countries (abstract 0292). Global Health Conference 2011.

7 EVALUATION OF PARTNERSHIPS

40


7.3 What, when and how to evaluate

7.3.1 What to evaluate

There are many measures of evaluation that

might be used. The choice will depend on the

nature of the programme (see Table 7.1).

Frequently evaluation uses quantitative methods.

Qualitative indicators are used less often yet

provide important information that cannot be

captured easily quantitatively. There was general

agreement that there is a need for a more

mixed-methods approach to evaluation that

integrates quantitative and qualitative measures.

7.3.2 When to evaluate

Plans for evaluation should be developed at

the outset of a partnership. Evaluation and

monitoring should occur at several stages:

planning, implementation, conclusion and

dissemination. Although there was consensus

that evaluation should occur regularly throughout

the partnership’s life, there were also concerns

that too early an evaluation could miss important

outcomes. Studies indicate that medical research

can take up to 17 years to move from the bench

to the bedside, and the careers of those who

receive training last a lifetime.68 The NIH Fogarty

Fellows AIDS International Training and Research

Programme (ATRIP) programme was highlighted

as an example of how an investment early in

a career can generate huge dividends decades

later but where too early an evaluation might

misleadingly indicate a poor outcome.

Outcomes such as changes to policy can

take a long time, so intermediate indicators

may be used such as increases in the level

of policy dialogue and requests for evidence

from policymakers. It is also often difficult to

disentangle the impact of the many different

contributions to policy change, which can

make the evaluation of particular initiatives

more difficult.

68 Academy of Medical Sciences, Medical Research Council & Wellcome Trust (2008). Medical research: what’s it worth? http://www.acmedsci.ac.uk/p99puid137.html

Table 7.1 Quantitative and qualitative indicators for use in evaluation

Quantitative indicators Qualitative indicators

• Number of degrees (Masters, PhDs,

postdoctoral).

• Number of started/completed graduate

programmes.

• Number of conference presentations.

• Number of postgraduate researchers.

• Number of publications in international,

local and national journals.

• Number of research grants (individual and

institutional).

• Number of staff also employed at

government agencies and NGOs.

• Number of research staff.

• Average time for PhD completion.

• Completed assignments and projects.

• Access to mentors.

• Career trajectories and promotions.

• Academic freedom (nature of faculty

employment, security of faculty

employment, nature of reward or

remuneration, level of control over teaching

and freedom to pursue any line of inquiry).

• Programme quality (leadership, decision

making).

• Teaching quality indicators

(teaching efficacy, teaching methods).

• Learning quality indicators

(learning attitude, ability to use knowledge).

• Learner’s confidence and competence in

research outcomes (attitudes, intentions and

actions towards research).

41


7.3.3 How to evaluate

In addition to the immediate need for evaluation

checklists for ongoing evaluations, it is

recognised that methods for the evaluation of

capacity building are still at an early stage of

development. Existing tools need to be tested,

and where a new more complex activity needs

to be captured, new methodologies may need

to be designed, which will also need testing.

Indicators also need to be revised regularly

to accommodate the changing nature of

partnerships.

The value of learning about evaluation tools

from other more experienced sectors, such

as business and economics, which already

possess tools for quality assurance systems,

was highlighted. There is also a need to use

the expertise from these other areas, such as

system specialists in designing evaluation around

complex interventions. The development of

expertise in evaluation science was seen as a

major opportunity for Southern institutions and

in the short-term more resources need to be

directed into training and building this expertise.

7.3.4 Evaluation toolkits and frameworks

There are several recently developed toolkits

and checklists available for use in ongoing

evaluations that all offer advice on how to

set up and run successful partnerships from

inception, implementation and dissemination.

These include ‘The Partnership Assessment

Toolkit’, ‘The Partnering Toolbook’ and ‘Making

an impact’.69,70,71 They provide practical advice

on establishing a vision for the partnership,

governance and management, roles and

responsibilities, ensuring good communication

and nurturing of the partnership over the lifespan

of the programme. A particular feature of the

Partnering Toolkit is a series of modifiable forms

and templates, including a partner assessment

form, a sample partnering agreement, guidelines

for partnering conversations and partners review

template, a case study template, and finally a

communication check list. There is the potential

to adapt these tools and templates to help

evaluate specific projects.

A framework for evaluation of different types of

EDCTP project is presented in Box 7.1.

69 Afsana K, et al. (2009). Partnership assessment toolkit. http://www.ccghr.ca/docs/PAT_Interactive_e.pdf70 Tennyson R (2003). The partnering toolbook. http://thepartneringinitiative.org/docs/tpi/pt/PartneringToolbookEng.pdf71 Canadian Academy of Health Sciences (2009). Making an impact: a preferred framework and indicators to measure returns on investment in

health research report. http://www.cahs-acss.ca/wp content/uploads/2011/09/ROI_FullReport.pdf

42


Box 7.1 Evaluation at the European and Developing Countries Clinical Trials Partnership (EDCTP)

The EDCTP was created in 2003 as a European response to the global health crisis caused by

three important poverty-related diseases: HIV/AIDS, malaria and tuberculosis. The mission of the

EDTCP is to accelerate the development of new or improved drugs, vaccines, microbicides and

diagnostics against HIV/AIDS, malaria and tuberculosis, with a focus on phase II and III clinical

trials in sub-Saharan Africa.

Further details about EDTCP can be found at http://www.edctp.org/Home.162.0.html

Three principles underpin the monitoring and evaluation of EDTCP.

1. Outputs and outcomes are agreed in advance and included in contracts.

2. Expected results are Specific, Measurable, Achievable, Relevant and Timely (SMART).

3. The need to change mechanisms of monitoring and evaluation as the partnership evolves is

recognised.

The monitoring and evaluation tools used by the EDCTP are as follows.

Capacity-building activity Verification process

Individual capacity building

Short-term training, project management,

financialmanagement,GCP/GCLP.

Periodicreports,sitevisitsbyfinancial

directorandfinanceteam,audits.

Long-term training (MSc, PhD), fellowships

(junior, senior).

Reports,certificates,publications,theses.

Institutional capacity building

Infrastructure (renovations, laboratory

upgrades, IT, etc.).

Periodic reports, site visits, audits,

questionnaires, inventories ‘before and after’

photographs, accreditations.

Personnel(projectmanagers,financial

administrators, nurses, etc.; training or hiring).

Periodic reports.

Institutional review boards. Periodic reports, Council on Health Research and

Development (COHRED) mapping, accreditation.

National capacity building

National ethics committees. Reports, site visits, mapping, African Vaccine

Regulatory Forum (AVAREF), activity reports.

National regulatory authorities. AVAREF activity reports, commissioning of

COHERED to undertake mapping.

Regional/supranational

Networks of excellence. Periodic reports, quarterly teleconferences,

questionnaires, site visits, publications, face to

face meetings

Pan-African clinical trials registry. Periodic reports, publications, inventories,

annual forum.

African Vaccines Regulators Forum. Annual forum, joint reviews.

43

7.4 Communicating and translating the results of evaluations into policy and practice

Evaluations should be communicated to

stakeholders and the results translated into

policy and practice. Too often, however,

evaluation reports are published only as

internal reports and go unnoticed. Several

participants also reported difficulties in getting

their evaluations published. Several medical

journals such as the Lancet, Public Library of

Science (PLoS) Medicine and the British Medical

Journal (BMJ) have supported the publication of

evaluative research especially from the South,

but there remains a lack of high-quality papers.

In addition, engaging ministers and policymakers

on long-term issues such the evaluation of global

health partnerships and capacity building may be

difficult if they are only in post for a few years.

7.5 Co-ordinating evaluation

On a global level, evaluation requires

better co-ordination. Currently there are no

internationally accepted evaluation tools,

and different funders have different reporting

requirements. Institutions can get overloaded

with multiple monitoring and evaluation schemes

from different funding organisations. The

transaction costs associated with evaluation

can be significant. Agreement on methods and

harmonisation of some of these processes will be

necessary to minimise the burden on institutions

with multiple partnerships.

Co-ordination might be improved through

a synthesis of evidence and lessons learnt

to provide a more robust basis for future

evaluations, and a publicly available registry

of major grants and independent evaluations.

It was noted, however, that this might be

challenging given the need to maintain

anonymity. An example of an initiative

established to co-ordinate evaluation is

Enhancing Support for Strengthening the

Effectiveness of National Capacity Efforts

(ESSENCE), which is detailed in Box 7.2.


Box 7.2 Enhancing Support for Strengthening the Effectiveness of National Capacity Efforts (ESSENCE)

ESSENCE on Health Research is an initiative between funding agencies to scale up co-ordination

and harmonisation of research capacity investments.72 It aims to improve the impact of

investments in institutions and people, and provides enabling mechanisms that address needs and

priorities within national strategies on research for health.

ESSENCE members embrace the principles of donor harmonisation and country alignment, as

expressed in the Paris Declaration on Aid Effectiveness in 2005 and enhanced by the Accra Agenda

for Action in 2008, both produced in collaboration with the Organisation for Economic Co-operation

and Development (OECD) Development Assistance Committee (DAC).

The ESSENCE collaboration has begun to collate different evaluation approaches (indicators and

summary narratives) by different funders. The aim is that in the future, interested parties can

select which ones are relevant for their particular purpose, and develop an adapted tool.

Further details are available from http://apps.who.int/tdr/svc/partnerships/initiatives/essence.

72 ESSENCE (2011). Planning, monitoring and evaluating framework for capacity strengthening in health research. http://apps.who.int/tdr/publications/non-tdr-publications/essence-framework/pdf/essence_framework.pdf

44

7.6 Ensuring accountability

Partnerships need to be accountable for their

outcomes and be able to demonstrate that

their funds are being spent appropriately.

This accountability is to individuals within

the partnership, institutions, governments

and countries. Evaluation can help increase

accountability and can play an important role in

attracting future funds and ensure initiatives are

sustainable.

Participants took the view that partnerships

should be accountable to the local communities

in which they conduct their work. Communities

often donate the land on which institutions are

built, as well as contribute directly to data and

samples on which research is undertaken. Given

the important role local communities have in

the success of partnerships, many participants

asserted that they should be able to expect direct

health and economic benefits from the research

conducted by the partnership. Local engagement

is more likely to help encourage support

from Southern governments and funders, as

previously discussed in Chapter 6.

7.7 Conclusion

Evaluation of partnerships is critical to

demonstrate benefits and impact, to assess

whether goals have been met and to

develop best practice. However, evaluation

is a new science that currently lacks a

strong evidence base with few validated

measures. Researchers, universities and

funders interested in global health research

should develop new methods of evaluation

for global health partnerships and capacity

building, along with a cadre of

experts in this field.

Key principles proposed for evaluating

partnerships included the following:

• The establishment of plans and funds

for rigorous, prospective evaluation at

the inception of partnerships.

• Regular evaluation throughout the

life of a partnership: at planning,

implementation, dissemination and

wrap-up.

• Joint development of evaluation tools

and indicators (quantitative and

qualitative) by partners and regular

revision to accommodate changes to the

nature of the partnership.

• The inclusion of measures of benefits to

local communities.

• The need to build on existing evaluation

tools with project-specific adaptations.

• Longer-term evaluation as some

outcomes of capacity-building activity

may take many years to show impact.

Additional priorities are as follows:

• To increase capacity with a cadre

of individuals trained in evaluation

methodology, especially in the South.

• To unify reporting requirements for

different funders to minimise onus on

institutions with multiple partnerships.

• To improve co-ordination of evaluation

tools and indicators through ESSENCE.

• To increase submission of high-quality

evaluation experiences to

peer-reviewed journals.


45

8 ENGAGING NEW DISCIPLINES, NEW TOPICS AND NEW PLACES

8 Engaging new disciplines, new topics and new places

8.1 Introduction

Participants highlighted new opportunities to

broaden global health partnerships and capacity

building beyond their existing boundaries. Two

areas that received particular attention were

engaging new disciplines and engaging new

places.

8.2 Engaging new disciplines

Disease-centred biomedical research alone will

not provide solutions to the complex global

health challenges of the 21st century. A more

co-operative interdisciplinary approach is now

required that involves a better understanding

of the many socio-cultural, economic and

environmental determinants of health. This

should integrate local knowledge with research

methodologies and expertise from different areas

including economics, social and environmental

science, engineering and mathematics.

Many participants believed that interdisciplinarity

has a greater potential for policy impact. For

example, senior decision makers, such as

ministers of finance, often do not have medical

backgrounds so are more likely to be persuaded

by the consensus view from an interdisciplinary

group. Moreover, there may be insufficient

evidence from any one discipline to forge policy

as different disciplines working alone may reach

different conclusions on the same question.

Box 8.1 describes approaches that have been

developed by three universities in the North

to enhance interdisciplinary working in global

health at their institutions. Lessons learnt

from experience at these centres include the

following:

• There is an enthusiasm among non-

biomedical disciplines to work in global

health, but also distrust and concern that it

will be dominated by biomedical scientists.

• One approach to overcoming these concerns

about ownership and control is to articulate

more clearly the benefits of collaboration,

and where necessary to provide resources

to another department to work on joint

projects, such as through salary support for

a member of their staff.

• It is preferable to keep collaborators based

in structures that encompass a critical mass

in their area of expertise rather than placing

them in new structures.

• High-level support from a university vice

chancellor or provost is important to support

the process.

Other successful examples of multisectorial

interdisciplinary groups working for global health


• One Health.73

• Stamp Out Sleeping Sickness.74

• IntegratedControlofNeglectedDiseases

(ICONZ).75

Despite the benefits of interdisciplinary research,

efforts to engage with other disciplines can

meet with resistance. There are concerns

about the potential impact of interdisciplinary

working on career development, and that the

current university career advancement and

reward system discourages applied collaborative

research. In addition, there remains a general

lack of skills among existing staff and trainees in

the use of appropriate terminology for effective

communication across disciplines.

There was broad consensus that an

interdisciplinary research ethos and related

skills should be incorporated into academic

training and career development as early as

possible. Interdisciplinary training programmes

and research opportunities, such as those

73 Further details of the One Health initiative are available from http://www.onehealthinitiative.com/74 Further details are available from http://www.stampoutsleepingsickness.com/75 Further details of the Integrated Control of Neglected Diseases are available from http://www.iconzafrica.org/

46


Box 8.1 Interdisciplinary centres for global heath

University of Washington

Four years ago the University of Washington set up a new interdisciplinary Department of Global

Health in collaboration with 17 other schools and colleges within the University, housed jointly

by the Schools of Medicine and Public Health. This has led to the creation of 19 interdisciplinary

centres or programmes, around 60 courses and over 300 projects in 82 countries, including the

multidisciplinary International Training and Education Center for Health (I-TECH) partnership.

I-TECH is one of the world’s largest health workforce training programmes, with offices throughout

Africa, Asia and the Caribbean.

Recent I-TECH developments include partnerships with the University of Namibia to strengthen

the Schools of Public Health, Medicine and Nursing, curriculum development in the new school of

Pharmacy, and a new Clinical Centre at University of Gondar, Ethiopia, that has involved University

of Washington architects and engineers.

Further information is available from http://www.go2itech.org/.

University College London Centre for Health and International Development (CIHD)

CIHD is an interdisciplinary collaboration of leading academics working on health and development

in a global context based at the Institute of Child Health, University College London. It was

established in October 2006 when the UCL Centre for International Child Health, the UCL

International Perinatal Care Unit and the UCL International Health & Medical Education Centre

united to become UCL CIHD.

It also houses and works closely with the UCL Institute for Global Health that supports the work

of UCL’s Grand Challenges. CIHD collaborates with a range of international agencies and NGOs

promoting the use of evidence-based good practice.

Further information is available from http://www.ucl.ac.uk/cihd/.

Global Health Academy at the University of Edinburgh

The Global Health Academy brings together a wide portfolio of postgraduate Masters degrees

relevant to global health from across the university, across different disciplines and across other

educational partnerships. It offers a range of qualifications in a variety of formats. One strength

is that students can take modules from other course and programmes. For example, a student

studying for a Masters in biodiversity, wildlife and ecosystem health can also take the social

determinants in public health module, which is part of the Masters in Public Health.

Further information is available from http://www.ed.ac.uk/schools-departments/global-health

discussed in Box 8.1, should be encouraged.

Social sciences, such as economics, geography

and psychology, are well placed to help shape

healthcare research. For example, understanding

human settlement patterns is important for

understanding many zoonotic diseases such as

sleeping sickness. Yet these disciplines are often

under-represented in interdisciplinary research

partnerships, particularly in Africa. Gaps in these

key disciplines need to be plugged.

Participants mentioned that even within the

47

biomedical sciences, global health research

partnerships have often focused on some areas

more than others. It was noted that even

though there is considerable support for HIV/

AIDS, tuberculosis and malaria, there are fewer

partnership initiatives aimed at areas such as

non-communicable diseases, nutrition, the social

determinants of health, health systems research

and evaluation methodology (see Chapter 7).

One challenge in engaging new disciplines

flagged by funders was that these areas often

lack a cadre of high-quality scientists able to

apply for funding and take the research forward.

In developing interdisciplinary research, the

principles of good partnership discussed in

Chapter 3 apply. However, interdisciplinarity

faces the additional challenge of uniting different

disciplines, often with disparate languages

and research methodologies. Ideas need to

be represented by a ‘language’ that avoids

unnecessary use of jargon and is accessible

to all involved. To this end, physical proximity,

strong leadership and enabling policies are

valuable. Most importantly, different sources

and levels of knowledge and training need to be

treated with the same level of respect. Finally,

the experience of Training for Health Equity

network (THEnet) and One Health is that if a

key goal is to implement and scale up findings,

early involvement of partners experienced

in community engagement, community

development, translation into policy and practice

is critical.

Many participants highlighted the need for

more funding for interdisciplinary research

projects. Joint funding initiatives, such as the

Environmental and Social Ecology of Human

Infectious Diseases Programme funded by

some of the UK Research Councils, should be

encouraged in other areas.76

Universities offer unique opportunities for

interdisciplinary working through their access

to multiple disciplines within a single institution.

A key challenge raised by participants is to how

to move from multidisciplinarity approaches,

where individual disciplines provide input, to

interdisciplinarity approaches, where disciplines

work together more synergistically.

8.3 Engaging new places

Global health partnerships span many different

geographical regions, but there are major gaps

(see Figure 8.1). Many partnerships on the

African continent are clustered in West Africa,

East Africa and Southern Africa, with an absence

of partnerships in the centre of the continent.

There is also insufficient engagement with

French- and Portuguese-speaking countries.

Often such circumstances arise because Northern

institutions tend to engage with Southern

institutions that are already well known, rather

than seeking new partners in new places. Such

gaps are exacerbated by language difficulties,

challenges in travelling between East Africa

and West Africa, and the problems in obtaining

resources to facilitate collaborations between

institutions in the South.

For example, several African participants

commented that it is easier for Southern

researchers to find resources to visit the USA

or Europe than neighbouring African countries.

This opinion is supported by a recent survey of

scientific authorship between 2004 and 2008

that showed 77% of African biomedical research

papers were produced with international

partners, whereas just 5% were the result of

collaborations with another African country.77

There was debate about whether the strategy to

address this should be to fill geographical gaps

by concentrating resources in a few excellent

institutions, or by spreading resources more

evenly. One suggested approach was a

hub-and-spoke model, with centres of excellence

in the South as the hub, and other, less strong

Southern institutions as spokes, as pioneered by

the Wellcome Trust African Institutions Initiative


76 Further details are available from http://www.mrc.ac.uk/Fundingopportunities/Calls/ESEI/index.htm 77 Royal Society (2011). Knowledge, networks and nations. http://royalsociety.org/policy/reports/knowledge-networks-nations/

48

and the EDCTP Centres of Excellence in Clinical

Trials.

8.3.1 Capacity building in fragile states

A major unrealised need and opportunity is the

establishment of global health partnerships

and capacity building in fragile states, states

emerging from conflict, or other low-income

countries with weak state institutions.

It was estimated at the conference that perhaps

one-fifth of the world’s population lives in fragile

states. Capacity building is critical here, because

these regions contain around one-third of the

world’s poor, one-third of all those living with

HIV/AIDS and around one-third of the burden

of maternal, newborn and child mortality. Yet,

according to one speaker, these states receive

40% less aid than that predicted on the basis of

their development indicators.

One speaker estimated that around 15% of


global research output comes from fragile states

but this is largely because of the existence of

a few outstanding institutions that continue

to support and attract research training and

capacity development in the face of crisis. Such

institutions must build and retain critical mass,

deal with issues of supply and infrastructure, and

overcome many financial and practical problems

with limited support from elsewhere.

Institutions in fragile states can represent

a worthy investment. Uganda, for example,

suffered decades of conflict, yet now has one of

the best biomedical research structures in Africa.

Conflict and challenge can spawn resilience and

ingenuity. Some of the most innovative research

partnerships have emerged from countries

facing crisis. Participants heard that currently

fragile states are not a priority for funders but

many believe that they should be for research,

although training might be better undertaken in

more stable environments.

Figure 8.1: Distribution of biomedical R&D capacity in Africa78

78 Nwaka S, et al. (2010). Developing ANDI: A Novel Approach to Health Product R&D in Africa. PLoS Medicine, 7(6), e1000293.

49

8.4 Conclusion

Growth in partnerships and capacity

has been uneven both geographically

and in the focus of their research and

the disciplines involved. The need for

interdisciplinary working is driven primarily

by the need for a more co-operative

approach to address complex global health

challenges. Universities and associated

partnerships offer a unique opportunity

for interdisciplinary working through their

ready access to multiple disciplines. Specific

strategies to promote interdisciplinary

working include the following:

• Expanding interdisciplinary training

programmes and research opportunities

such as exchange of modules from

different courses or distance learning

programmes.

• Incorporating interdisciplinary

training opportunities early into career

structures.

• Promoting interdisciplinary research

funding schemes.

• Increasing representation of social

sciences, such as psychology, nutrition

and health economics, in existing

partnerships.

• Encouraging recognition and reward

for interdisciplinary working within the

university sector.

• Greater efforts are needed to establish

equitable, sustainable partnerships

and capacity in both underserved

regions such as central Africa, French-

and Portuguese-speaking countries,

and fragile states, and in neglected

disciplines and topics such as health

systems research, nutrition, the social

determinants of health and

non-communicable diseases.


50


51

9 CONCLUSION

9 Conclusion

Over the past decade or so there has been a

rapid increase in the number and variety of

global health partnerships between academic

institutions. These new alliances offer

considerable benefits to participants as well

as the opportunity to tackle the Millennium

Development Goals and build research, education

and health service capacity, particularly in the

South. They are, however, accompanied by costs

with inequity and sustainability as major barriers

to success.

Five priority areas for action emerged from the

conference.

• Nurturing postdoctoral fellows and

postgraduate students.

• Strengthening institutions.

• Engaging decision makers and funders from

the South.

• Developing evaluation.

• Involving new disciplines and new places.

For global health partnerships to flourish, these

priorities must be taken forward by individuals

and institutions in the North and South, national

academies of medical science, professional

bodies, funders, industry, government agencies,

local communities, charities and NGOs.

Inevitably the conference was limited in what

it could showcase. Although there was a strong

representation from Africa, other regions such

as the Middle East and China were less well

represented. Many of the partnerships covered

at the conference concerned infectious diseases

whereas fewer concerned non-communicable

diseases. These might be addressed through

future activities.

52


53

Annex I: Organising and Steering committees

Organising Committee• Professor Philippa Easterbrook, Associate Director of Global Health, Royal College of Physicians

(Co-Chair and Conference Organiser)

• Professor Robert Souhami CBE FMedSci, Foreign Secretary, Academy of Medical Sciences

(Co- Chair and Conference Organiser)

• Neva Frecheville, International Officer, Royal College of Physicians

• Laurie Smith, Policy Manager, Academy of Medical Sciences

Steering Committee• Professor Philippa Easterbrook, Associate Director of Global Health, Royal College of Physicians


• Professor Robert Souhami CBE FMedSci, Foreign Secretary, Academy of Medical Sciences


• Dr Fiona Adshead, Director of Health Advice, PriceWaterhouseCoopers

• Sue Bernhauser, Dean of the School of Human and Health Sciences, University of Huddersfield

• Joe Cerell, Director of Europe Office, Bill and Melinda Gates Foundation

• Professor Jonathan Cohen FMedSci, Dean, Brighton and Sussex Medical School

• Professor Tumani Corrah, Unit Director, MRC the Gambia

• Professor Anthony Costello FMedSci, Director of UCL Institute for Global Health, University College

London

• Dr Nina Desai, Deputy Director, The George Institute for Global Health

• Professor Alan Fenwick, Director of the Schistosomiasis Control Initiative, Imperial College London

• Professor Andrew Green, Professor of International Health Planning, University of Leeds

• Professor Sir Andrew Haines FMedSci, Professor of Public Health and Primary Care, London School

of Hygiene and Tropical Medicine

• Professor Janet Hemingway FRS FMedSci, Director, Liverpool School Tropical Medicine

• Dr Richard Horton FMedSci, Editor, The Lancet

• Eve Jagusiewicz, Policy Advisor, Universities UK

• Professor Anne Johnson FMedSci, Head of Division for Public Health, University College London

• Professor David Lalloo, Director Wellcome Trust Tropical Centre, Liverpool School of Tropical

Medicine

• Professor Anthony Mbewu, Former Director, Global Forum on Health Research

• Professor Charles Mgone, Chief Executive, European and Developing Countries Clinical Trials

Partnership

• Professor Robyn Norton, Principal Director, George Institute for Global Health

• Professor Barbara Parfitt, Director Global Health Development, Glasgow Caledonian University

• Professor Vikram Patel FMedSci, Professor of International Mental Health, Goa, and Institute of

Psychiatry

• Professor Neslon Sewankambo, Principal, College of Health Sciences, Makerere University

• Professor Chris Whitty FMedSci, Chief Scientific Advisor and Head of Research, Department for

International Development

• Professor James Whitworth FMedSci, Head of International Activities, The Wellcome Trust

The first draft of the report was prepared by Dr Helen Pilcher.

ANNEX I: ORGANISING AND STEERING COMMITTEES

54


55

SUMMARY

Annex II: Acronyms and abbreviations

ANNEX II: ACRONYMS AND ABBREVIATIONS

ANDi African Network for Drugs and Diagnostics Innovation

ASTIEF African Science, Technology and Innovation Endowment Fund

ATRIP AIDS International Training and Research Programme

AusAID Australian Agency for International Development

BMJ British Medical Journal

CARTA Consortium for Advanced Research Training in Africa

CCGHR The Canadian Coalition for Global Health Research

CDC US Centers for Disease Control

CIHD Centre for Health and International Development

COHRED The Council on Health Research for Development

CPLP Community of Lusophonic Countries

CUGH Consortium of Universities for Global Health

DAC Development Assistance Committee

DfID Department for International Development

DNDi Drugs for Neglected Diseases initiative

EAGHA European Academic Global Health Alliance

EDCCTP European and Developing Countries Clinical Trials Partnership

ESSENCE Enhancing Support for Strengthening the Effectiveness of National Capacity Efforts

G-Finder Global Funding of Innovation of Neglected Diseases

GAVI Global Alliance for Vaccination and Immunisation

GET Ghana Educational Trust Fund

HDSS Health and Demographic Surveillance Systems

I-TECH International Training and Education Center for Health

ICEMR International Centres for Malaria Research

ICONZ Integrated Control of Neglected Diseases

INDEPTH The International Network for the Demographic Evaluation of Populations and

Their Health in Developing Countries

ISHReCA Initiative to Strengthen Health Research Capacity in Africa

KPFE The Commission for Research Partnerships with Developing Countries

MCDC The Malaria Capacity Development Consortium

MUNDO Maastricht University Centre for International Cooperation in Academic Development

NGOs non-governmental organisations

MEPI Medical Education Partnerships Initiative

NACCAP Netherlands-African Partnership for Capacity Development

NIH National Institutes of Health

OECD Organisation for Economic Co-operation and Development

PACTR Pan African Clinical Trials Registry

PATH Programme for Appropriate Technology in Health

PGIM Post-Graduate Institute of Medicine

PHFI Public Health Foundation of India

PLoS Public Library of Science

PPPs Public Private Partnerships

RAWOO The Netherlands Development Assistance Research Council

SIDA Swedish International Development Agency

SMART Specific, Measurable, Achievable, Relevant and Timely

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TDR Special Programme for Research and Training in Tropical Diseases

THEnet Training for Health Equity network

THET Tropical Health Education Trust

UNASUR Union de Naciones Suramericanas

UNECA United Nations Economic Commission for Africa

USAID United States Agency for International Development

WACP West African College of Physicians

WHO World Health Organization


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Academy of Medical Sciences 41 Portland Place London, W1B 1QH

+44(0) 20 3172 2150 [email protected]

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